Quality

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

Can quality measurement and comparisons serve as the backbone for a major shift in the Medicare payment system to reward value instead of volume? That is the question being explored over the next few years as the Physician Quality Reporting System (PQRS) and, by extension, the physician value-based payment modifier (VBPM) come fully into effect for all physicians.

There seems to be a consensus in the policy community that the fee-for-service model of payment is past its prime and needs to be replaced with a more dynamic and responsive payment system. Medicare hopes that PQRS and the VBPM will enable adjustments to physician payments to reward high-quality and low-cost care. Although these programs currently are add-ons to the fee-for-service system, they likely will serve as stepping stones to more radical departures from the existing payment system.

SHM advocates refinements to policies for PQRS and similar programs to make them more meaningful and productive for both hospitalists and the broader health-care system. Each year, SHM submits comments on the Physician Fee Schedule Rule, which creates and updates the regulatory framework for PQRS and the VBPM. SHM also provided feedback on Quality and Resource Use Reports (QRURs), the report cards for the modifier that were being tested over the past year.

From a practical standpoint, SHM engages with measure development and endorsement processes to ensure there are reportable quality measures in PQRS that fit hospitalist practice. In addition, SHM is helping to increase accessibility to PQRS reporting by offering members reduced fare access to registry reporting through the PQRI Wizard.

The comments range from the technical aspects of individual quality measures in PQRS to how hospitalists appear to be performing in these programs. SHM firmly believes that the unique positioning of hospitalists within the health-care system presents challenges for their identification and evaluation in Medicare programs. In some sense, hospitalists exist on the line between the inpatient and outpatient worlds, a location not adequately captured in pay-for-performance programs.

It’s imperative that pay-for-performance programs have reasonable and actionable outcomes for providers. If quality measures are not clinically meaningful and do not capture a plurality of the care provided by an individual hospitalist, it is difficult for the program to meet its stated aims. If payment is to be influenced by performance on quality measures, it follows that those measures should be relevant to the care provided.

There is a long way to go toward creating quality measurement and evaluation programs that are relevant and actionable for clinical quality improvement (QI). By becoming involved in SHM’s policy efforts, members are able to share their experiences and impressions of programs with SHM and lawmakers. This partnership helps create more responsive and intuitive programs, which in turn leads to greater participation and, hopefully, improved patient outcomes. As these programs continue to evolve and more health professionals are required to participate, SHM will be looking to its membership for their perspectives.

Join the grassroots network to stay involved and up to date by registering at www.hospitalmedicine.org/grassroots.

Joshua Lapps is SHM’s government relations specialist.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

Clostridium difficile infection (CDI) is a common and costly bacterial illness in hospitalized patients, involving 1% of U.S. hospital stays with an aggregate cost of $8.2 billion annually.¹ The spore-forming, gram-positive bacillus is spread by the fecal-oral route; in health-care settings, it is often transmitted by hand carriage and contamination of environmental surfaces. C. diff produces toxins that can cause a spectrum of diseases, including asymptomatic carriage, mild to severe diarrhea, colitis, and pseudomembranous colitis, which in severe cases can lead to sepsis, colectomy, or death.

CDI is defined as the acute onset of diarrhea in a patient with documented toxigenic C. diff or C. diff toxin, without any other clear cause of diarrhea.² In the past decade, CDI has increased in frequency and severity, with most experts thinking it is related to a particularly virulent strain known as BI/NAP1/027.3 Antibiotic exposure is the most significant and modifiable risk factor for CDI, with increasing age, gastric acid suppression, and immunocompromised states also placing patients at increased risk for developing infection.

Guideline Analysis

In February, the American College of Gastroenterology (ACG) released guidelines for diagnostic testing and pharmacologic therapy for CDI, management of complicated and recurrent disease, and infection control and prevention.² Previous recommendations for the prevention, diagnosis, and treatment of CDI have been provided by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and a collaboration of the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).^4,5 Recommendations addressing CDI in infants and children are also available.⁶ The 2013 ACG guidelines are the first from this group to address CDI and are intended to supplement previously published guidelines.

Diagnostic testing. The ACG guidelines emphasize that only stools from patients with diarrhea be tested for C. diff and/or its toxin. Colonization with C. diff is common, and performing tests in asymptomatic patients may complicate clinical care. Rarely, patients with CDI will develop ileus, and in those cases, rectal swab may be performed, but in nearly all circumstances, only diarrheal stools warrant testing. The authors also strongly discourage repeat testing after a negative test and testing for cure following treatment and resolution of symptoms. All of these recommendations are consistent with the SHEA-IDSA guidelines and reflect moderate- to high-quality evidence.

Recognizing that diagnostic testing for C. diff continues to evolve, the ACG makes specific recommendations regarding the use of newer tests, such as nucleic acid amplification and glutamate dehydrogenase detection. These are favored over toxin A and B enzyme immunoassay testing due to higher sensitivity.

Management of mild, moderate, and severe CDI. As with prior guidelines, the 2013 ACG guidelines stratify treatment recommendations by disease severity. Mild to moderate disease, which includes diarrhea only (mild) or diarrhea with signs and symptoms not meeting criteria for severe or complicated CDI (moderate), should be treated with metronidazole 500 mg orally three times daily for 10 days. Oral vancomycin should only be used in patients with mild to moderate disease who fail to respond after five to seven days of metronidazole or in those who are intolerant to metronidazole, or pregnant or breastfeeding. Although fidaxomicin is FDA-approved to treat mild to moderate CDI, the ACG does not make a formal recommendation on its use, given its high cost and limited data to support its effectiveness.

The ACG defines severe disease as CDI in patients with albumin <3 g/dL, and either WBC ≥15,000 cells/mm3 or abdominal tenderness. Though this definition of severe disease differs from the ESCMID and SHEA-IDSA definitions, which include elevated creatinine (>50% greater than premorbid level) instead of low albumin, the treatment recommendation is the same: vancomycin 125 mg orally four times daily for 10 days. While vancomycin and metronidazole are equally effective in mild to moderate CDI, there is some evidence to suggest that vancomycin is more effective in severe disease.⁷

Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.

Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.

Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.

Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.

There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.

Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.

Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.

HM Takeaways

The 2013 ACG guidelines for the diagnosis, treatment, and prevention of CDI are generally consistent with previously published guidelines from ESCMID and SHEA-IDSA. Ongoing points of emphasis are the following:

1. Only test patients with diarrhea;
2. Do not repeat testing after a negative test or after completion of treatment;
3. Promptly discontinue any inciting antibiotics;
4. Avoid use of anti-peristaltic agents; and
5. Treat based on disease severity.

Hospitalists should be aware of criteria that place patients into the severe and complicated category, and understand that initial treatment should be provided for a 10-day course. These guidelines also highlight the need for a high index of suspicion and low threshold for empiric treatment in immunocompromised patients.

Finally, hospitalists should be attentive to antibiotic stewardship and strictly adhere to contact precautions and hand hygiene with soap and water, as these behaviors have been shown to prevent and control CDI.

Dr. Cunningham Sponsler is a hospitalist in the section of hospital medicine at Vanderbilt University in Nashville, Tenn.

References

1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed June 17, 2013.

2. Surawicz CM, Brandt LJ, Binion DJ, et al. Guidelines for diagnosis, treatment and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-498.

3. Freeman J, Bauer MP, Baines SD, et al. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev. 2010;23:529-549.

4. Bauer MP, Kuijper EJ, van Dissel JT. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance for Clostridium difficile infection (CDI). Clin Microbiol Infect. 2009;15:1067-1079.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control and Hosp Epidemiol. 2010;31:431-455.

6. Committee on Infectious Diseases. Clostridium difficile infection in infants and children. Pediatrics. 2013;131:196-200.

7. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302-307.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

In June, the Robert Wood Johnson Foundation announced a national competition for technology developers to help consumers understand and utilize data for comparing the prices of hospital procedures. Winners of the foundation’s Hospital Price Transparency Challenge, to be announced later this year, will share $120,000 in prizes for intuitive, actionable tools leading to more transparent hospital pricing in two categories.

One category involves the creation of visual aids that would help consumers and others better understand the Centers for Medicare & Medicaid Services’ (CMS) hospital-cost data, which was released in May and compares widely variable hospital prices for 100 common inpatient procedures. The other category involves developing applications and tools that could help consumers price-shop.

The foundation is offering support and opportunities for submitters to interact with experts and technical innovators. The deadline for applications is Aug. 25.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

A Joint Commission Sentinel Event Alert released this spring tackles “alarm fatigue” resulting from the constant beeping of medical-device alarms and information being broadcast from these devices. If not properly managed, the proliferation of alarms can put hospitalized patients at serious risk because the barrage of warning noises can desensitize professional caregivers or distract them from truly critical alarms. U.S. Food and Drug Administration data show that 566 hospital deaths from 2005 to 2008 were alarm-related, while the Joint Commission’s own sentinel-events database lists 80 alarm-related deaths in the same period.

The commission urges hospital leaders to look at this serious patient-safety issue. “By making alarm safety a priority, lives can be saved,” said Ana McKee, MD, the commission’s executive vice president and chief medical officer.

Among its recommendations:

• Ensure that there is a process for safe alarm management and response in high-risk areas;
• Prepare an inventory of alarm-equipped medical devices in these high-risk areas;
• Regularly inspect, check, and maintain the devices; and
• Establish guidelines for alarm settings, including situations in which alarm signals are not clinically necessary.

The commission, which participated in a 2011 summit of national safety and medical-technology organizations seeking solutions to the problem, is considering the possible promulgation of a national patient-safety goal on alarm fatigue, a draft of which was field-tested in February and released for public comment.

Larry Beresford is a freelance writer in San Francisco.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

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. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

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. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

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. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

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.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

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.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

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.

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.