Tuesday, May 21, 2013

Medical office efficiency - the times they are a wastin'

Medical practices, particularly private businesses like mine, strive for efficiency. This has become more necessary as medical reimbursements inexorably decline while overhead and other expenses rise. This may be the point in this post when a reader will jump to the comment section below and carp how I and every other doctor are only in it for the money. Not so fast here. Yes, I would like to make a living and I believe that I deserve a decent one. In my case, I do not seek, and have never sought wealth. For small private medical groups, particularly in northeast Ohio, we are aiming to survive more than to thrive.

These days wasted time during the work week can be the tipping point that buries a private practice.

Where are the time sinkholes in medical practice?

No show patients. This is the Wonder Bread of medical practices. It torments doctors in 12 different ways. Younger readers may need to Google to get this reference.

Late patients. While these folks are less sinful than Wonder Bread patients, they mangle the schedule and suck up physician and staff time. Should these patients be told that they need to reschedule? How late does a patient have to be before he is ejected from the office? Should he be told to sit tight in the waiting room until all of the on-time patients have been seen? Are we comfortable playing hardball with a 90-year-old woman who hobbles in on her walker 20 minutes late?

Delays in receiving requested medical records. Even in the electronic era, it can be mind boggling how much work is required to get a few papers faxed over. For doctors, this task becomes a competition where we gird our loins to beat the system.

Patient paperwork. Our new patients fill out medical surveys that our staff then uploads manually into our EMR (electronic medical record) system. Although these folks are told to arrive early, it never seems to be early enough. I often find myself in solitude in the exam room while the expected patient is in the waiting room pushing paper. In time, this clumsy process will be compressed and expedited, but our practice is not there yet.

Down on the Pharma. This is the improvised explosive device of medical practices. I cannot calculate how much time is vaporized re-prescribing medications that are not, or no longer on, the preferred list. If we guess the right medication, then we err on the number of pills permitted. If we opt for the mail order pharmacy, we learn that the local drug store was the proper destination. And, of course, if we were insane enough to memorize a particular patient's proton pump inhibitor prescription pathway, it changes at year's end.

There may be other reasons that challenge medical office efficiency. Perhaps, for instance, there is the rare instance when a physician is late. In this instance, any of my patients who are reading this post are invited not to comment.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Labels: electronic medical records, guest post, humor, MD Whistleblower, Michael Kirsch, practice management

Wording change affects surrogates' end-of-life choices for loved ones

Small wording changes made big differences in end-of-life decisions for surrogates of critically ill patients, a study found.

Researchers conducted a web-based simulated meeting to discuss code status using 256 volunteers randomly assigned to consider a hypothetical scenario in which their spouse or parent was receiving life-sustaining treatment in an intensive care unit. An actor portrayed an intensivist, who at the end of the interview discloses a 10% likelihood of survival in the event of cardiac arrest requiring cardiopulmonary resuscitation (CPR). The actor then asked surrogates to decide the patient's code status.

Results of the study, co-authored by Robert M. Arnold, MD, FACP, appeared online at Critical Care Medicine.

While emotional triggers didn't influence the outcomes, researchers noted that three framing manipulations that mattered included implying the social norm was not to choose CPR, phrasing that the decision was the patient's vs. the surrogate's, and describing the alternative to CPR as "allow natural death" vs. "do not resuscitate [DNR]."

Emotional triggers--seeing pictures and scenarios with the loved one as opposed to seeing neutral scenes before making the choice about CPR--did not impact CPR choice. But framing the social norm as not choosing, rather than choosing, CPR resulted in fewer decisions to resuscitate (48% vs 64%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.32 to 0.87), as did framing the alternative to CPR as "allow natural death" rather than DNR (49% vs 61%; OR, 0.58; 95% CI, 0.35 to 0.96).

Researchers wrote, "[W]e provide the first empiric evidence that this phrase, which has been integrated into the language of several health systems, may directly influence code status decisions."

Angelo Volandes, MD, ACP Member, tells The Atlantic that unwanted end-of-life treatments are "wrongful care." He describes a project that will teach patients and surrogates How Not to Die.

An experience he had as a medical resident showed him that patients needed to see examples of end-of-life care--what a CPR attempt is really like--for them to understand what's involved in that decision. He and Aretha Delight Davis, MD, ACP Associate Member, are now creating videos to show surrogates who may face such decisions.

Dr. Volandes told The Atlantic, "Videos communicate better than just a stand-alone conversation. And when people get good communication and understand what's involved, many, if not most, tend not to want a lot of the aggressive stuff that they're getting."

Labels: CPR, end of life, ethics, intensivist

Why surgical complications may actually hurt hospital profits, despite what you've read

If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce it?

There's a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and determined that admissions that included a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors concluded that this creates a disincentive for hospitals to prevent surgical complications since they might see reduced profits as a result.

This is a very provocative finding and it's getting a lot of well-placed media attention, as you might expect. However, there is an important caveat with the study that I would like to highlight.

In the study the authors report that admissions with surgical complications result in $39,000 higher "profits" if the care is reimbursed via a private payer and $1,800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial, "Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services." His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a U.S. hospital.

This is what the authors assumed (and mentioned as a limitation): "We did not estimate the effect of 3 potential factors that could affect the hospital economics of surgical complications. First, the shorter lengths of stay of procedures without complications could benefit the small percentage of hospitals operating at full capacity because they might be able to admit additional patients with favorable insurance who were 'crowded out'" What this means is that they didn't include any profits that might be generated by an empty bed filled with a second (or third or fourth) patient. In the study, around 5% of patients developed a complication and stayed an excess of 11 days (at the median)--the mean would be higher.

Note: Based on recommendations of Johns Hopkins professor and retired CFO, Bill Ward, we focused on estimating the costs of HAI using return-on-investment calculations from filling empty beds that manifest through HAIs avoided in the Business-Case SHEA Guideline. In discussions he suggested that excess bed capacity is quickly taken off line and therefore doesn't impact economic evaluation to a large degree. If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce length of stay?

The big question: Do you believe that 5% of beds in hospitals with high surgical volumes sit completely empty for almost two weeks? Of course, there is excess capacity in the US system, but the amount of excess capacity is most important here, not that it exists. You can't completely ignore profits from increased admissions. For example, if only one patient was admitted into a bed vacated by a "healthy" patient discharged at day three that would have otherwise been occupied by a patient with a surgical complication discharged at day 14, the results of the study would be have been negated--i.e., it would have been a negative study. If more than one patient was admitted into an empty bed over 11 days, which seems likely at most high-volume hospitals, admissions with surgical patients with complications would result in reduced profits compared with admissions without complications. It would have been nice to see estimates of the excess capacity at the 12 hospitals under study.

A provocative study and wonderful analysis. However, as Dr. Reinhardt states, the study "provides important data on a pressing clinical and financial problem affecting hospitals" yet "much of this represents a shell game of how costs are allocated." I would add, and which profits are included or excluded.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

Labels: Controversies in Hospital Infection Prevention, discharge, Eli N. Perencevich, guest post, hospital costs, patient safety

If cops can have K9s, why not docs?

During the Update in HM session at HM 2013, speaker Michelle Mourad delighted the audience by telling about a study that found beagles have a 100% success rate in sniffing out C diff in stool samples, which is a better success rate than existing lab tests.
Meanwhile, cats, or at least one cat named Oscar, have shown an ability to determine who is about to die. And it's pretty well known that animals are comforting and calming to the sick, old and infirm.

So the question is, how long before some enterprising pet store chain suggests a strategic partnership with a hospitalist group? I believe the term "hospetalist" is still up for grabs....

Labels: hm13, Hospital Medicine 2013

Team leading

There's been a lot of generic advice about team leadership delivered at this conference. There is no "I" in team, I learned yesterday. But wait, I heard this morning, actually there is a "me." It's just separated and backwards: team.

But mixed in with these questionably inspirational sayings have also been some useful tips. One that's come up a couple times: Don't forget to let the front-line people know how your team effort (quality improvement project, patient satisfaction initiative, etc) is going. Give them data whenever it's available, and give them frequent rewards (parties, pizza, thank you notes) when it's good.

Also, patient anecdotes are your friends. Collect them and share them. Whether positive or negative, they can be a strong motivator for change, for anyone from the front-line staff to the hospital board.

And finally, while we may all be sick of word games with the word "team," making up your own cheesy marketing slogan can be very effective. Speakers at yesterday's session on QI mentoring described how hospitals have improved inpatient glucose control with easy-to-remember campaigns focused on blood glucose targets, like "Let's do a 180" or "2 over 200."

Labels: hm13, Hospital Medicine 2013

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Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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Related ACP Resources:

ACP Hospitalist

Tuesday, May 21, 2013

Medical office efficiency - the times they are a wastin'

Wording change affects surrogates' end-of-life choices for loved ones

Monday, May 20, 2013

Why surgical complications may actually hurt hospital profits, despite what you've read

Saturday, May 18, 2013

If cops can have K9s, why not docs?

Team leading

Contact ACP Hospitalist

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