A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

A study is underway to assess the impact of a dermatologist’s consultation for patients admitted to the hospital with cellulitis.

Started last October, the randomized controlled trial is comparing patients overseen by internal-medicine hospitalists alone to those who are also evaluated by a dermatologist soon after admission to Massachusetts General Hospital in Boston. Daniela Kroshinsky, MD, MPH, the principal investigator, hypothesizes that hospital admission for cellulitis involving consultation with a dermatologist might decrease length of stay, readmission rates, incidence of pseudocellulitis, cost, and/or antibiotic usage.

“We did a similar study in the outpatient setting that demonstrated over 80 percent reduction in antibiotic use,” says Dr. Kroshinsky, the hospital’s director of pediatric dermatology and director of inpatient dermatology, education, and research.

Patients in the control group are instructed to follow hospitalists’ recommendations solely. This includes the timing and type of post-discharge appointments. As part of the standard of care, these patients can consult with a dermatologist if necessary or requested.

Patients randomized to the treatment group receive a consultation with a dermatologist, along with treatment recommendations. They also have a follow-up visit in a dermatology clinic after discharge. Both groups will be assessed for readmission or complications.

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

Experienced hospitalists and medical directors agree that the key to multiple hospitalist groups coexisting effectively under one roof—whether directly competing or not—is good communication. Effective communication can take time to build.

“Start by working together on something—anything, [such as] a hospital committee of some sort where there’s not likely to be much tension,” says hospitalist pioneer and practice consultant John Nelson, MD, MHM.

Dr. Nelson practices at Overlake Hospital in Bellevue, Wash., which has a hospitalist group employed by the hospital and another employed by Group Health Cooperative, a nonprofit health system in Washington state. It is important to put some trust in the trust bank, he says, “and that’s hard if you have no social connections at all. At my hospital, we enjoy each other’s company, we visit each other at lunch, and we even tried to have a journal club.” The two hospitalist groups work together on developing care protocols. Dr. Nelson says it also makes sense for the groups’ leaders to sit down together on a regular basis and have a venue for discussing important issues and solving problems that may arise.

Other suggestions for hospitalist groups working together under one roof include:

• Clearly define each group’s territory. The groups’ representatives can go out and try to persuade health plans or physician groups to shift their hospitalist allegiances, but there should be no “trolling” or “poaching” of patients going on inside the hospital’s walls. That will only confuse patients and disrupt the hospital’s larger service goals.
• Inform the ED and other key staff of your schedules. It’s important that everyone know exactly who is supposed to get which patients, and how these referrals get made. But recognize that mistakes happen and, hopefully, these will even out between the groups over time.
• Transparency, honesty, and even-handed treatment of all hospitalists can prevent resentment. Clearly defined guidelines and expectations are helpful. If the policy spells out transfers for an incorrectly referred patient, both sides should be accessible and cooperative with that process.
• Identify areas of common interest and agree to work together on these areas (i.e. competition-free zones). It might be possible, for example, for competing groups to take each others’ after-hours call on a rotating basis, with a firm commitment not to steal patients along the way.
• Spell out responsibilities in a way that everyone can agree is fair, such as alternating referrals or taking call on alternating days. For example, if subsidies are paid to more than one hospitalist group, is this done equitably, such as based on the number of hospitalist FTEs or shifts?
• Restrictive covenants and contractual noncompete clauses could become an issue in areas where multiple groups practice. Rather than using overly broad, blanket language, it could be clarified that such pacts apply only to the hospital where the physician currently works, and within a reasonable time frame. But everyone involved should be aware of what these covenants contain and, if they appear unreasonable, don’t sign them.

—Larry Beresford

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.”¹ Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.

Comprehensive Service

Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).² The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:³

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).

The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.

Critical/Key Portion

“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:³

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).

“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:³

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).

EHR Considerations

When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”

Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.

Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.

Students

CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.

Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.

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

References

1. Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
2. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
4. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

Dr. Vinik

1. Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
2. Attend dermatology lectures as part of primary care’s continuing medical education courses.
3. Review a good basic dermatology atlas from time to time.
4. Learn to correctly describe lesions to a dermatologist by phone.
5. Don’t assume that groin rashes are all fungal.
6. Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
7. Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
8. Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
9. Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
10. Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
11. Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
12. Be mindful of the rapid onset of purpuric lesions on the skin.
13. Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
14. Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
15. Encourage patients to follow up with a dermatologist on an outpatient basis.

Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.

“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.

Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).

“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”

Dr. Vinik

The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.

The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.

Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”

Maintain a broader range of differential diagnoses before ruling in or out something more concrete.

“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.

“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

Attend dermatology lectures as part of primary care’s continuing medical education courses.

This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.

Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.

Review a good basic dermatology atlas from time to time.

This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.

Learn to correctly describe lesions to a dermatologist by phone.

When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.

Don’t assume that groin rashes are all fungal.

In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.

Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.

It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.

Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.

There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.

Dr. Schwarzenberger

“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”

Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.

“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”

It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”

Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.

Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.

“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”

If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.

For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.

Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.

These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.

Dr. Aires

“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”

Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.

This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.

Be mindful of the rapid onset of purpuric lesionscon the skin.

They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”

13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.

Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.

Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”

As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.

“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists. It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”

—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston

Encourage patients to follow up with a dermatologist on an outpatient basis.

By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.

“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”

Susan Kreimer is a freelance writer in New York.

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.¹ As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.

The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).

Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.

No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.

Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).

It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.

—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver

Purposeful, Team-Based Medicine

Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.

Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.

“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.

As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.

The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.

A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.

“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”

The ISSF contract contains such performance incentives.

“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”

And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.

We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide. We need to be more organized, structured, and purposeful in an era of team-based medicine.

—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.

Supply and Demand

Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.

“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”

The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.

The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.

“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”

In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)²

Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.

Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.

“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”

Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.

“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”

Impact of Health-Care Reform

Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.

Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.

“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
2. Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.

The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.

SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.⁵

The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.

In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.⁵

The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.

In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.⁵

The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.

In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.² The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.

With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.³ Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.⁴ According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.² The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.

With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.³ Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.⁴ According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.² The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.

With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.³ Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.⁴ According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
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