Practice Management

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

 

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

 

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

 

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

---

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

 

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

 

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

 

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

 

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

---

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

 

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

 

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

 

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

 

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

---

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

 

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

 

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

 

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

 

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one ormore of the “key communication” tactics in practice to maintain provider accountability for “Everything we say and do that affects our patients’ thoughts, feelings and well-being.”

As providers, how do we define the patient experience? Over the past year, I have had the pleasure of working with a dedicated group of 15 fellow members on the newly formed SHM Patient Experience Committee. One of our first goals was to define the patient experience in a way that acknowledges our role and its potential impact on patients as emotional beings and not just vessels for their disease.

To this end, we define the patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.

Although it’s true that patients bring with them their own history and narrative that contribute to their experience, we cannot change that. We can only adjust our own behaviors and actions when we seek to elicit or respond to patients’ concerns and goals.

And although “everything we say and do” is inclusive of providing the most effective and evidence-based medical care at all times, we believe that accurate clinical decision making absolutely must be accompanied by superior communication. By offering clear explanations, listening compassionately, and acknowledging patients’ predicaments with empathy and caring statements, we can restore a degree of humanity to our care that will allow patients to trust that we have their best interests in mind at all times. This is our role in improving the patient experience.

Beginning next month, members of the Patient Experience Committee will be sharing key communication skills and interventions that each of us believes to be important and effective. Each member will share what they do, why they do it, and how it can be done effectively. The items we’ll be focusing on will be taken from the “Core Principles” and “Key Communications,” as compiled by the committee (see Table 1, below). Some have evidence to back them up. Some are common sense. All of them are simply the right thing to do.

We hope you’ll reflect on “everything we say and do” each month as well as share it with your colleagues and teams. And we need look no further for a winning argument to focus on the patient experience than Sir William Osler and one of his most famous quotes: “The good physician treats the disease; the great physician treats the patient who has the disease.”

We’re going for great. Are you with us? TH

Dr. Rudolph is vice president of physician development and patient experience for Tacoma, Wash.–based Sound Physicians. He is chair of SHM’s Patient Experience Committee.

Table 1.

---

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one ormore of the “key communication” tactics in practice to maintain provider accountability for “Everything we say and do that affects our patients’ thoughts, feelings and well-being.”

As providers, how do we define the patient experience? Over the past year, I have had the pleasure of working with a dedicated group of 15 fellow members on the newly formed SHM Patient Experience Committee. One of our first goals was to define the patient experience in a way that acknowledges our role and its potential impact on patients as emotional beings and not just vessels for their disease.

To this end, we define the patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.

Although it’s true that patients bring with them their own history and narrative that contribute to their experience, we cannot change that. We can only adjust our own behaviors and actions when we seek to elicit or respond to patients’ concerns and goals.

And although “everything we say and do” is inclusive of providing the most effective and evidence-based medical care at all times, we believe that accurate clinical decision making absolutely must be accompanied by superior communication. By offering clear explanations, listening compassionately, and acknowledging patients’ predicaments with empathy and caring statements, we can restore a degree of humanity to our care that will allow patients to trust that we have their best interests in mind at all times. This is our role in improving the patient experience.

Beginning next month, members of the Patient Experience Committee will be sharing key communication skills and interventions that each of us believes to be important and effective. Each member will share what they do, why they do it, and how it can be done effectively. The items we’ll be focusing on will be taken from the “Core Principles” and “Key Communications,” as compiled by the committee (see Table 1, below). Some have evidence to back them up. Some are common sense. All of them are simply the right thing to do.

We hope you’ll reflect on “everything we say and do” each month as well as share it with your colleagues and teams. And we need look no further for a winning argument to focus on the patient experience than Sir William Osler and one of his most famous quotes: “The good physician treats the disease; the great physician treats the patient who has the disease.”

We’re going for great. Are you with us? TH

Dr. Rudolph is vice president of physician development and patient experience for Tacoma, Wash.–based Sound Physicians. He is chair of SHM’s Patient Experience Committee.

Table 1.

---

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one ormore of the “key communication” tactics in practice to maintain provider accountability for “Everything we say and do that affects our patients’ thoughts, feelings and well-being.”

As providers, how do we define the patient experience? Over the past year, I have had the pleasure of working with a dedicated group of 15 fellow members on the newly formed SHM Patient Experience Committee. One of our first goals was to define the patient experience in a way that acknowledges our role and its potential impact on patients as emotional beings and not just vessels for their disease.

To this end, we define the patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.

Although it’s true that patients bring with them their own history and narrative that contribute to their experience, we cannot change that. We can only adjust our own behaviors and actions when we seek to elicit or respond to patients’ concerns and goals.

And although “everything we say and do” is inclusive of providing the most effective and evidence-based medical care at all times, we believe that accurate clinical decision making absolutely must be accompanied by superior communication. By offering clear explanations, listening compassionately, and acknowledging patients’ predicaments with empathy and caring statements, we can restore a degree of humanity to our care that will allow patients to trust that we have their best interests in mind at all times. This is our role in improving the patient experience.

Beginning next month, members of the Patient Experience Committee will be sharing key communication skills and interventions that each of us believes to be important and effective. Each member will share what they do, why they do it, and how it can be done effectively. The items we’ll be focusing on will be taken from the “Core Principles” and “Key Communications,” as compiled by the committee (see Table 1, below). Some have evidence to back them up. Some are common sense. All of them are simply the right thing to do.

We hope you’ll reflect on “everything we say and do” each month as well as share it with your colleagues and teams. And we need look no further for a winning argument to focus on the patient experience than Sir William Osler and one of his most famous quotes: “The good physician treats the disease; the great physician treats the patient who has the disease.”

We’re going for great. Are you with us? TH

Dr. Rudolph is vice president of physician development and patient experience for Tacoma, Wash.–based Sound Physicians. He is chair of SHM’s Patient Experience Committee.

Table 1.

---

 

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

 

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

---

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

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

 

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

---

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

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

 

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

---

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

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Dear Dr. Hospitalist:

Over the past several years, we have had a problem with physician retention, especially with nocturnists, in our medium-sized hospitalist group. Do you have any suggestions (beyond the obvious “more money”) to help us retain our hospitalists?

Missing My Friends in the Midwest

Dr. Hospitalist responds:

Since its inception, hospital medicine has been a very attractive field for practicing medicine, and although growth was phenomenal for many years (especially 2000–2010), it has leveled off over the past five years. With this exceptional growth have come increased salaries, geographically diverse job locations, and more opportunities for career development.

One of the most significant changes over the past 10 years is that hospital medicine is no longer seen as a bridge from residency to fellowship or as a stopover while waiting on the ideal job. Physicians now see hospital medicine as a career choice and are more likely to search for the “ideal” hospitalist job.

Although competitive salaries are important and a necessary starting point, to attract and keep career hospitalists, HM groups (HMGs) will need to offer opportunities for professional growth and leadership as well as flexible schedules.

Many larger HMGs offer several different schedule models, from the ubiquitous seven-on/seven-off schedule (54%, according to the 2014 State of Hospital Medicine report) to the more traditional five-day workweek with vacation time. Many also choose to work part- or full-time as a nocturnist and, in doing so, earn substantially more money (15%–20% differential). The flexible schedule and the ability to work part- or full-time have been very attractive to those clinicians just starting families or attaining another degree (MBAs are becoming very popular).

While there have always been the “check-in, check-out” docs who did their seven and didn’t want to be bothered during their time off, there were typically enough gunners around to pick up the slack. With the Millennial generation’s pervasive aim for work-life balance, it might become more difficult to find even a few who are willing to go the extra mile in hopes of career advancement. Mix in a very robust job market with a proclivity to travel, and you have a recipe for high attrition.

Like any new profession or specialty, HM will have to evolve and adjust to keep these new docs anchored. We will need to consider offering vacation time, especially for those who are willing to work a traditional Monday–Friday schedule. For those in academia with an interest in promotion, there should be real opportunities for advancement instead of the traditional “time in rank” and other nebulous requirements. There should be robust mentoring for all docs and especially for those just out of residency. The clinicians who express an interest in having an office in the C-Suite should be given a clear path and guidance.

I think with some innovation and recognition, most HMGs will have little problem retaining high-quality physicians. We must also recognize a changing value system and accept that some people will change jobs just because! TH

Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?

 

Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?

 

Nick Fitterman, MD, SFHM, vice chair of hospital medicine for the Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., and North Shore-Long Island Jewish Health System in New Hyde Park, N.Y., discusses how hospital medicine factors into population health—where is the intersection and what is the hospitalist’s role?

 

We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.

We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?

First of Its Kind

David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.

Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1

Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.

A New Paradigm?

In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.

 

And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.

So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.

I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

 

References

1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.

2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.

We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.

We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?

First of Its Kind

David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.

Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1

Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.

A New Paradigm?

In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.

 

And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.

So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.

I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

 

References

1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.

2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.

We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.

We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?

First of Its Kind

David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.

Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1

Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.

A New Paradigm?

In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.

 

And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.

So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.

I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

 

References

1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.

2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

 

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

---

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

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

 

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

---

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

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

 

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

---

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

When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.¹

According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”¹ The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.

This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.

Valid Codes

Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”² This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.

The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.

For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.

Code Families

Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”³ Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.

For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.

 

The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.

For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).

Affected Claims

As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”³ The review contractors included are as follows:

• Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
• Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
• Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
• Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).⁴

This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).

For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.

Non-Medicare Payer Considerations

Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:

• Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
• Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
• Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
• General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
• “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.^5,6,7

---

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

 

References

1. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
2. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
3. Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
4. Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
5. Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
6. Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
7. Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.

Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.¹

According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”¹ The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.

This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.

Valid Codes

Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”² This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.

The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.

For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.

Code Families

Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”³ Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.

For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.

 

The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.

For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).

Affected Claims

As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”³ The review contractors included are as follows:

• Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
• Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
• Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
• Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).⁴

This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).

For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.

Non-Medicare Payer Considerations

Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:

• Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
• Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
• Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
• General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
• “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.^5,6,7

---

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

 

References

1. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
2. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
3. Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
4. Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
5. Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
6. Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
7. Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.

Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.¹

According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”¹ The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.

This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.

Valid Codes

Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”² This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.

The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.

For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.

Code Families

Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”³ Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.

For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.

 

The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.

For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).

Affected Claims

As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”³ The review contractors included are as follows:

• Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
• Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
• Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
• Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).⁴

This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).

For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.

Non-Medicare Payer Considerations

Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:

• Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
• Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
• Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
• General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
• “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.^5,6,7

---

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

 

References

1. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
2. Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
3. Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
4. Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
5. Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
6. Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
7. Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.