Back when I first became a nurse and I thought it was fun to wear a little white hat and white hose, things were different. I had spent my childhood walking 20 miles to and from school and as the mores of the time dictated; it was always through 5 feet of snow and uphill, of course, both ways. I didn’t expect my life or job to be easy.
Thursday, October 22, 2009
What was it like being a nurse in the olden days?
Tuesday, August 11, 2009
Tuesday, June 2, 2009
Congruence: The Challenge of Charge Capture
In the past decade we have witnessed many changes in the way healthcare services are reimbursed. Just when one regulation starts to make sense they manage to come up with new and often confusing requirements to muddy the waters just as they are beginning to clear. The one constant mantra however has remained “if it wasn’t documented, it wasn’t done”. Now those of us who have spent time delivering care in the ED know painfully well; patients don’t stagger themselves so that you may have the luxury of completing your documentation (eating your lunch, using the bathroom, grabbing the ubiquitous diet coke, wiping the stray body fluids off your scrubs…you get the idea).
The other often over-looked challenge is ED documentation is primarily for the downstream consumer. We need little documentation to communicate in the ED. Our patients (in theory) turn around relatively quickly, unlike the inpatient setting where documenting days or weeks of treatments, tests, consults and medications are required to communicate and coordinate care.
Irrespective, we just can’t seem to get away from the old “if it wasn’t documented, it wasn’t done”. This is especially true for charge capture. Let’s look at the story of Larry an ED patient that presents with chest pain. Larry loves your ED and visits often, he has a history of MI and pops in to the ED every now and then with chest pain. This is a scary patient because we know that we must take any complaints of chest pain seriously but most of the time he is completely pain-free and ready to go home after a little nitro and of course 2mg-10mg of morphine titrated to pain. When Larry presents to triage the triage nurse calls back for a monitored bed, he is placed on a cardiac monitor, given O2, IV access is established, and a 12 lead ECG is completed as well as a stat portable chest x-ray (we all know how this story goes). The ED physician comes in see what’s going on, writes the order for MS and probably a nitro drip. 2 or 3 hours later Larry’s pain is gone and he is instructed of course to follow-up with his doctor and return to the ED immediately if his pain is returns. By now you are saying; what’s your point Suzy?
The point is unless everything done for Larry was ordered and documented in Larry’s record your ED cannot charge for it. So the ED doctor saw the patient was on the monitor therefore didn’t write the order. The primary nurse didn’t clearly document the start and stop time of the nitro drip and the morphine IV push was not clearly documented, by the way documenting on your charge sheet DOES NOT count. So Larry’s visit just cost your ED approximately $151. Doesn’t seem like much, huh? But let’s say you see 35,000 visits annually in your ED and 25% of them receive the same treatment protocol as Larry, the documentation is inadequate ONLY 10% of the time, if you look at the numbers at the end of the year your ED will have lost approximately $132,000 or let’s say you miss it 30% of the time, the number goes to $396,000!
So evaluate congruence! Look at your orders and documentation, find the opportunities for improvement (I guarantee you have them!), communicate with the ED staff where you are (current state) and define a plan and strategy for where you want to be (future state). Finally, the numbers above are very conservative; many ED Directors know that the dollar figure for lost ED charges is frequently in the millions! Remember now more than ever; if it wasn’t documented, it wasn’t done!
The other often over-looked challenge is ED documentation is primarily for the downstream consumer. We need little documentation to communicate in the ED. Our patients (in theory) turn around relatively quickly, unlike the inpatient setting where documenting days or weeks of treatments, tests, consults and medications are required to communicate and coordinate care.
Irrespective, we just can’t seem to get away from the old “if it wasn’t documented, it wasn’t done”. This is especially true for charge capture. Let’s look at the story of Larry an ED patient that presents with chest pain. Larry loves your ED and visits often, he has a history of MI and pops in to the ED every now and then with chest pain. This is a scary patient because we know that we must take any complaints of chest pain seriously but most of the time he is completely pain-free and ready to go home after a little nitro and of course 2mg-10mg of morphine titrated to pain. When Larry presents to triage the triage nurse calls back for a monitored bed, he is placed on a cardiac monitor, given O2, IV access is established, and a 12 lead ECG is completed as well as a stat portable chest x-ray (we all know how this story goes). The ED physician comes in see what’s going on, writes the order for MS and probably a nitro drip. 2 or 3 hours later Larry’s pain is gone and he is instructed of course to follow-up with his doctor and return to the ED immediately if his pain is returns. By now you are saying; what’s your point Suzy?
The point is unless everything done for Larry was ordered and documented in Larry’s record your ED cannot charge for it. So the ED doctor saw the patient was on the monitor therefore didn’t write the order. The primary nurse didn’t clearly document the start and stop time of the nitro drip and the morphine IV push was not clearly documented, by the way documenting on your charge sheet DOES NOT count. So Larry’s visit just cost your ED approximately $151. Doesn’t seem like much, huh? But let’s say you see 35,000 visits annually in your ED and 25% of them receive the same treatment protocol as Larry, the documentation is inadequate ONLY 10% of the time, if you look at the numbers at the end of the year your ED will have lost approximately $132,000 or let’s say you miss it 30% of the time, the number goes to $396,000!
So evaluate congruence! Look at your orders and documentation, find the opportunities for improvement (I guarantee you have them!), communicate with the ED staff where you are (current state) and define a plan and strategy for where you want to be (future state). Finally, the numbers above are very conservative; many ED Directors know that the dollar figure for lost ED charges is frequently in the millions! Remember now more than ever; if it wasn’t documented, it wasn’t done!
Wednesday, March 25, 2009
T-System Value in a Nut shell
Podcast interview with Suzy (Wier) Thorby, Chief Nursing Officer of T-System (transcript)
July 28th, 2008 by David E. Williams of the Health business blog This is a transcript of my recent podcast interview with T-System’s Suzy Thorby. http://www.healthbusinessblog.com/?p=1862
David Williams: This is David Williams, co-founder of MedPharma Partners and author of The Health Business Blog. I’m speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales and Relationship Management with T-System, a leading provider of clinical documentation solutions for emergency departments. Suzy, thanks for being with me today.
Suzy Thorby: Thank you, David. I appreciate the opportunity.
David: Suzy, what is the T-System?
Suzy: The T-System is a chief complaint-specific documentation tool for clinicians in the emergency department. For example, if somebody presents with chest pain in the emergency department (most of our cases present as new, undiagnosed problems), we take the chief complaint, and, basically, if they have pneumonia or costochondritis or an acute MI, you’re able to rule out the highest risk things. It helps pull together the things that are most critical on any presentation. It brings your quality indicators to the bedside with you. We do that both with paper documents and our electronic documentation, which is a natural extension of paper products.
David: Tell me about how the emergency room is different. It sounds like people are presenting with undiagnosed problems, potentially of an urgent nature and without a lot of background knowledge of them. How is it different from what things would be like elsewhere in the hospital?
Suzy: Well that is a very good point. There is a different standard of care for the emergency department because if someone presents to the ED, they have a different expectation than going to the day surgery area or to their physician’s office. They’re actually frightened enough or sick enough to come to the emergency department. We’re held to a different standard of care. You don’t really have a diagnosis when they come. Even if you have someone with asthma and it’s an acute exacerbation, perhaps they’re presenting today with pneumonia. You have an episode-based document versus a document that supports the continuum. It becomes part of the continuum but you have an acute episode of a chronic illness or a new illness that is presenting. In that way the chief complaint-specific documentation works very well. You wouldn’t say someone presents with asthma, you would say someone presents with shortness of breath. That way you’re able to make sure if it’s just an exacerbation of their asthma or they have pneumonia, you’ve captured the data that helps support the appropriate disposition and plan of care for that patient.
David: It sounds like you have both a paper system and an electronic extension as well. Can you talk about the relationship between those two and also how paper versus electronic documentation has different sorts of issues, in the emergency department versus other places?
Suzy: Yes. We developed the paper system in 1995 and 1996 because of the burden of remembering all the documentation guidelines, when CMS first came out with all the documentation guidelines. It is very onerous, making decisions on patient care and providing care when you are trying to remember these guidelines, so the paper system developed as a way to say, if this is what CMS says is an appropriate level of service, let’s make sure we get those things into a document. It becomes very difficult to remember how many reviews you have done or how many elements of a physical exam. What we did with the paper is basically presented them in a way that was specific to the patient’s complaint. We incorporated in 1996 and it was astonishing because at that time less than one percent of the EDs had any templated documentation. Basically, everybody thought that dictation was the gold standard. Because dictation tends to be a narrative, you would get the story but miss the elements that supported your level of service. What we did is we made a data centric model that not only captures the clinical data but supports the level of service. Again, we found that we were able to take things like QA elements right to the bedside. It was a data push rather than a data pull. We were able to push the standards out in a way that physicians could use it at the point of care versus going back retrospectively and finding that the data was missing.
David: It sounded like when you were starting off that a very small percentage of people were actually using a templated system. So you’re basically replacing a free form system. Is that still the case today when you go into a new customer? What would be the typical state of play? Would it be completely free form or would they have some sort of homegrown system or some competitor in place already?
Suzy: Interestingly, we have about 30 percent of the EDs in the U.S. where the physicians use the T-sheets. I think that is significant because the more users that we have, the better the documents become. It’s a living body of knowledge. It’s not static. We didn’t develop the templates and they’ve stayed the same. We’ve actually received input from thousands of physicians, compliance officers, reimbursement specialists –and the documents continue to evolve. It’s a dynamic process. But the biggest challenge was that it was a free form, so you’d have to make a right brain/left brain switch, where you’re used to gathering the data in a storytelling format and now you’re gathering data at the point of care that ultimately support your clinical impression. I would say it’s the difference between a tape and a CD. If my favorite song on a tape is number five, I have to fast forward or rewind to it. If it’s a CD, I go right to the information I need and I can document it in a nonlinear way. The other key thing is that we were able to do it at the bedside in parallel with the patient visit. You would be able to capture data in a nonlinear way at the bedside and therefore be able to spend more time with the patient at the bedside. Not too many patients are saying, ‘That ED physician spent way too much time with me while I was in the department.’ It solves so many problems that it was astonishing. You didn’t have to wait for a registration clerk to put somebody in the system before you could start doing your documentation. You didn’t have to wait until you had all your lab and x-rays back. You could get the history, your physical exam and you could do it again in parallel with the whole visit, which helped with a lot of bottlenecks.
David: Now that you’ve gotten up to 30 percent penetration, what are the key drivers these days? Is it simply that when someone comes into an ED that’s not using the T-System they’ll say, gee, we should really have this because this is what I’m used to and it makes so much more sense? How much of a driver is pay for performance?
Suzy: Look, for example, at Keystone Physicians. You have to consider if you have multiple emergency departments as a physician group that you’re staffing, you have such wide variability of documentation. They said, we will make the commitment to standardize our documentation and even the playing field across our sites. If you think about all the new things that come out as far as documentation guidelines, present on admission criteria, pay for performance, not only by CMS but now various third party payers, it’s overwhelming to try to remember all of those things when you’re taking care of a patient and also to remember the critical things on a presentation. If somebody came in with back pain, you don’t want to sit down and do your dictation and ask, ‘Did I check femoral pulses? I can’t remember.’ Maybe you have to call them up and have them come back to the ED, which I actually had a physician tell me he did. It’s better to have the data there with the patient. Whether it is clinical data, quality data, utilization data, CMS data, or quality indicators, having it there during the point of care makes a huge difference in how consistently you capture it. Then you can compare across your enterprise if everyone is doing it the same way. You can make changes according to your practice. So, for example, Keystone Physicians is really helping in meeting their clinical and business objectives based on a prototype that we provide.
David: Keystone is an outsourced emergency department group so they’re working across different areas. Would they have some of their same employees or contractors working across multiple sites?
Suzy: Frequently, if you live in one town and they staff two hospitals, they’ll go from hospital to hospital. Again you’re really decreasing variability and allowing the physician to focus on the thing that is most important, which is medical decision making and patient care.
David: When a hospital is deciding to implement the TSystem or is evaluating it against other sorts of systems or keeping things the same, what is the typical process that you go through and how do they look at it? Who are the constituencies that are involved and do they evaluate financial measures, clinical measures, safety measures, or risk management/defensibility measures? How do they look at it?
Suzy: All of those. It varies by site. Dictation is very expensive and we see the margins in health care decreasing and you get no consistent ability to capture data. They tend to vary widely based on a provider rather than a tool. They will look at things like, ‘What does this do for our bottom line as far as dictation?’, also the medical/legal exposure because you’re able to take your QA indicators to the bedside. You’re able to capture things that support standard of care for the practice of emergency medicine. Additionally, you’re able to have physicians spending more time with patients. A lot of hospitals CEOs are very concerned about their Press Ganey scores or whatever tool they’re using to measure patient satisfaction. You also have utilization review, who’s saying, ‘We need to make sure that we have this documentation if we’re going to have an admission. ’ We have present on admission criteria now, which say that if you don’t have it documented that a patient had a urinary tract infection at the time they were admitted, CMS is not going to reimburse you for treatment of that. We generally have a positive impact on reimbursement just because you’re able to get a lot of consistency. Again, it’s right there. You see what you need to document. I always say with a caveat, if you’re a high performing organization, we want to make you better performing. Maybe you don’t increase reimbursement but you see an extra patient every two hours because you’re able to do it in parallel with the visit as opposed to many documentation methodologies that have to be done in sequence. You cannot begin a dictation until you have everything back on a patient and have made a disposition. It’s the ability to get consistent documentation, to do it in parallel with the visit, to break up the bottlenecks in the ED and provide the quality indicators and the clinical indicators that really help make care better.
David: What do you find in terms of how hospitals look at T-System within the context of their overall information strategy? For example, do you find a hospital that’s doing a general digitization push but then also would consider putting in the paper-based T-System at that time? Do they tend to go with the electronic T-System or do they say, “Gee, as part of our comprehensive package we’re going to bring in some other solution because it’s integrated in with our main system that we’re putting in’?
Suzy: A lot of people have a long term IT strategy that says they’re going to have a single enterprise vendor. However, the clinical verticals aren’t that well built out on enterprise vendors. They take the overarching clinical premise and try to make that work in the ED. Because the ED is such a unique environment, you don’t necessarily have the ability to take, for example, a consult in the office where you’re doing follow up on hypertension and make that work in the ED. It’s building out those verticals on the large horizontal platform that is a challenge. So, people may say, long term, that they’re going to go to an enterprise vendor, but there’s not really one that leverages the technology to make the work flow better, the clinical care better, that has a content that is really collaborative content, not specific to what that hospital needs. And, I think that’s an overarching strategy. I use Salesforce.com every day. Salesforce works very well for me because they understand my work flow. The technology leverages what I do. And in one of your blogs, somebody said, ‘Getting adoption is difficult with clinicians’. And, it is one of those things that if you don’t leverage their current work flow, it is very difficult to be successful. And you may be successful from an IT perspective with some applications, but we say your core competency in a hospital is patient care. We leverage the current work flow and the processes to make the patient care better, not detract from it. And I think we do that uniquely. And also, our content, because it is dynamic, because we get feedback from users, because we’re constantly updating our content, that makes a huge difference in how people are able to use it and realize the benefits.
David: Suzy, I see on your website, a picture of what looks to me like a motion C5 Mobile Clinical Assistant computer and I have to ask you about that since my friend, Scott Eckert, is the founder of that company. Do you work with Motion Computing and what’s your impression of them?
Suzy: Yes, we do. We have a great relationship with Motion. We have them at a lot of our sites. It’s amazing to me when we first started to implement our electronic record that the mobile devices weren’t what they are now. You’d have to stand right over it. They weren’t as rugged. And the connectivity was not as good. Now we’re finding that, with the Motion devices, we get great connectivity. We have great screen resolution, great screen size, and the images are so much better. Handwriting recognition is so much better. What was really a difficult thing to get people to transition to at one point is now easier and easier so they can basically take that device to the bedside and capture the history, the past family social history, review a physical exam. It’s basically the paper sheet metaphor with a mobile device.
David: You’ve been at this for 12 years, or so. I’m sure you’re not counting, but it’s been a while. If you look ahead five years or so, what would you think might be the biggest difference between where we are today and what you’ll see at that point in time?
Suzy: Well, I think the biggest differences that I see are these quality measure initiatives or value-based purchasing both within CMS and third-party payers. Now, there are those who would say ‘This is payment reform in sheep’s clothing’, and that may not be too far from the truth. It is basically saying, the fee for service, making more money by delivering more services is not what we want to pay for. We want to pay for appropriate care, appropriate utilization. We don’t want to pay for something that you created in the hospital, for example, pneumonia or a decubitus ulcer, or a urinary tract infection. That train has left the station and gained speed every day. I’m actually on a work group with the AMA and HIMSS to say ‘How are we going to get electronic records to report on this so that we have consistent, reproducible, quality data on patients when they present? How are we defining the data? How are we recording the data? How is it extracted?’ Those are all things that are going to happen, are already happening. It increases every day. And so my thinking is that in five years we’re going to be seeing a lot of value-based purchasing and quality measures that must be reported to get reimbursement. So, pay for performance for physicians now is sort of a voluntary thing that you get a little bonus. My thinking is that if you don’t do it, your percentage of Medicare fee schedule is going to drop, or as Aetna’s doing in California, they’re going to say ‘If you are not one of our certified quality providers, you won’t be in network’. And you put the quality stamp on anything and it’s hard for beneficiaries or hospitals or employers to say it’s not good. But, I think it needs to be watched carefully because there are some agendas that could be followed if it’s not implemented and recorded appropriately and well defined. My issue is that they have quality measures that are poorly defined at times. You’re going, ‘how do we make sure that if this is a quality measure, it’s being measured consistently and predictably across, not just a site, but a state, a system. How are we doing that consistently?’
David: There’s a lot of talk about consumerism in health care and I would say the Emergency Department might be the last place that you’d expect to see it, but tell me if I’m wrong there or how that might change. Is consumerism something that is actually coming to the floor in the Emergency Department as well, or are patients still pretty much passive when they come in?
Suzy: No, I think a lot of times what you’ll see is that people will have looked something up before they come in. They’ll have sort of run through the WebMD, ‘What do I think I have’, and will come in with sort of an idea of what they think their plan of care should be. That is something we see in Emergency Departments all the time now. There are still a lot of patients who will acquiesce to whatever the clinicians tell them when they get to the department, but we’re seeing that more and more. And that empowerment is good. It would be nice at some point for us to have good data on cost/benefit ratios to say, ‘We can do this and it will cost you x, we can do this, it’s 2x and your outcome is going to be the same’.
David: I’ve been speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales in Relationship Management at T-System. Suzy, thank you for your time today.
Suzy: Thank you very much, David. I enjoyed it.
July 28th, 2008 by David E. Williams of the Health business blog This is a transcript of my recent podcast interview with T-System’s Suzy Thorby. http://www.healthbusinessblog.com/?p=1862
David Williams: This is David Williams, co-founder of MedPharma Partners and author of The Health Business Blog. I’m speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales and Relationship Management with T-System, a leading provider of clinical documentation solutions for emergency departments. Suzy, thanks for being with me today.
Suzy Thorby: Thank you, David. I appreciate the opportunity.
David: Suzy, what is the T-System?
Suzy: The T-System is a chief complaint-specific documentation tool for clinicians in the emergency department. For example, if somebody presents with chest pain in the emergency department (most of our cases present as new, undiagnosed problems), we take the chief complaint, and, basically, if they have pneumonia or costochondritis or an acute MI, you’re able to rule out the highest risk things. It helps pull together the things that are most critical on any presentation. It brings your quality indicators to the bedside with you. We do that both with paper documents and our electronic documentation, which is a natural extension of paper products.
David: Tell me about how the emergency room is different. It sounds like people are presenting with undiagnosed problems, potentially of an urgent nature and without a lot of background knowledge of them. How is it different from what things would be like elsewhere in the hospital?
Suzy: Well that is a very good point. There is a different standard of care for the emergency department because if someone presents to the ED, they have a different expectation than going to the day surgery area or to their physician’s office. They’re actually frightened enough or sick enough to come to the emergency department. We’re held to a different standard of care. You don’t really have a diagnosis when they come. Even if you have someone with asthma and it’s an acute exacerbation, perhaps they’re presenting today with pneumonia. You have an episode-based document versus a document that supports the continuum. It becomes part of the continuum but you have an acute episode of a chronic illness or a new illness that is presenting. In that way the chief complaint-specific documentation works very well. You wouldn’t say someone presents with asthma, you would say someone presents with shortness of breath. That way you’re able to make sure if it’s just an exacerbation of their asthma or they have pneumonia, you’ve captured the data that helps support the appropriate disposition and plan of care for that patient.
David: It sounds like you have both a paper system and an electronic extension as well. Can you talk about the relationship between those two and also how paper versus electronic documentation has different sorts of issues, in the emergency department versus other places?
Suzy: Yes. We developed the paper system in 1995 and 1996 because of the burden of remembering all the documentation guidelines, when CMS first came out with all the documentation guidelines. It is very onerous, making decisions on patient care and providing care when you are trying to remember these guidelines, so the paper system developed as a way to say, if this is what CMS says is an appropriate level of service, let’s make sure we get those things into a document. It becomes very difficult to remember how many reviews you have done or how many elements of a physical exam. What we did with the paper is basically presented them in a way that was specific to the patient’s complaint. We incorporated in 1996 and it was astonishing because at that time less than one percent of the EDs had any templated documentation. Basically, everybody thought that dictation was the gold standard. Because dictation tends to be a narrative, you would get the story but miss the elements that supported your level of service. What we did is we made a data centric model that not only captures the clinical data but supports the level of service. Again, we found that we were able to take things like QA elements right to the bedside. It was a data push rather than a data pull. We were able to push the standards out in a way that physicians could use it at the point of care versus going back retrospectively and finding that the data was missing.
David: It sounded like when you were starting off that a very small percentage of people were actually using a templated system. So you’re basically replacing a free form system. Is that still the case today when you go into a new customer? What would be the typical state of play? Would it be completely free form or would they have some sort of homegrown system or some competitor in place already?
Suzy: Interestingly, we have about 30 percent of the EDs in the U.S. where the physicians use the T-sheets. I think that is significant because the more users that we have, the better the documents become. It’s a living body of knowledge. It’s not static. We didn’t develop the templates and they’ve stayed the same. We’ve actually received input from thousands of physicians, compliance officers, reimbursement specialists –and the documents continue to evolve. It’s a dynamic process. But the biggest challenge was that it was a free form, so you’d have to make a right brain/left brain switch, where you’re used to gathering the data in a storytelling format and now you’re gathering data at the point of care that ultimately support your clinical impression. I would say it’s the difference between a tape and a CD. If my favorite song on a tape is number five, I have to fast forward or rewind to it. If it’s a CD, I go right to the information I need and I can document it in a nonlinear way. The other key thing is that we were able to do it at the bedside in parallel with the patient visit. You would be able to capture data in a nonlinear way at the bedside and therefore be able to spend more time with the patient at the bedside. Not too many patients are saying, ‘That ED physician spent way too much time with me while I was in the department.’ It solves so many problems that it was astonishing. You didn’t have to wait for a registration clerk to put somebody in the system before you could start doing your documentation. You didn’t have to wait until you had all your lab and x-rays back. You could get the history, your physical exam and you could do it again in parallel with the whole visit, which helped with a lot of bottlenecks.
David: Now that you’ve gotten up to 30 percent penetration, what are the key drivers these days? Is it simply that when someone comes into an ED that’s not using the T-System they’ll say, gee, we should really have this because this is what I’m used to and it makes so much more sense? How much of a driver is pay for performance?
Suzy: Look, for example, at Keystone Physicians. You have to consider if you have multiple emergency departments as a physician group that you’re staffing, you have such wide variability of documentation. They said, we will make the commitment to standardize our documentation and even the playing field across our sites. If you think about all the new things that come out as far as documentation guidelines, present on admission criteria, pay for performance, not only by CMS but now various third party payers, it’s overwhelming to try to remember all of those things when you’re taking care of a patient and also to remember the critical things on a presentation. If somebody came in with back pain, you don’t want to sit down and do your dictation and ask, ‘Did I check femoral pulses? I can’t remember.’ Maybe you have to call them up and have them come back to the ED, which I actually had a physician tell me he did. It’s better to have the data there with the patient. Whether it is clinical data, quality data, utilization data, CMS data, or quality indicators, having it there during the point of care makes a huge difference in how consistently you capture it. Then you can compare across your enterprise if everyone is doing it the same way. You can make changes according to your practice. So, for example, Keystone Physicians is really helping in meeting their clinical and business objectives based on a prototype that we provide.
David: Keystone is an outsourced emergency department group so they’re working across different areas. Would they have some of their same employees or contractors working across multiple sites?
Suzy: Frequently, if you live in one town and they staff two hospitals, they’ll go from hospital to hospital. Again you’re really decreasing variability and allowing the physician to focus on the thing that is most important, which is medical decision making and patient care.
David: When a hospital is deciding to implement the TSystem or is evaluating it against other sorts of systems or keeping things the same, what is the typical process that you go through and how do they look at it? Who are the constituencies that are involved and do they evaluate financial measures, clinical measures, safety measures, or risk management/defensibility measures? How do they look at it?
Suzy: All of those. It varies by site. Dictation is very expensive and we see the margins in health care decreasing and you get no consistent ability to capture data. They tend to vary widely based on a provider rather than a tool. They will look at things like, ‘What does this do for our bottom line as far as dictation?’, also the medical/legal exposure because you’re able to take your QA indicators to the bedside. You’re able to capture things that support standard of care for the practice of emergency medicine. Additionally, you’re able to have physicians spending more time with patients. A lot of hospitals CEOs are very concerned about their Press Ganey scores or whatever tool they’re using to measure patient satisfaction. You also have utilization review, who’s saying, ‘We need to make sure that we have this documentation if we’re going to have an admission. ’ We have present on admission criteria now, which say that if you don’t have it documented that a patient had a urinary tract infection at the time they were admitted, CMS is not going to reimburse you for treatment of that. We generally have a positive impact on reimbursement just because you’re able to get a lot of consistency. Again, it’s right there. You see what you need to document. I always say with a caveat, if you’re a high performing organization, we want to make you better performing. Maybe you don’t increase reimbursement but you see an extra patient every two hours because you’re able to do it in parallel with the visit as opposed to many documentation methodologies that have to be done in sequence. You cannot begin a dictation until you have everything back on a patient and have made a disposition. It’s the ability to get consistent documentation, to do it in parallel with the visit, to break up the bottlenecks in the ED and provide the quality indicators and the clinical indicators that really help make care better.
David: What do you find in terms of how hospitals look at T-System within the context of their overall information strategy? For example, do you find a hospital that’s doing a general digitization push but then also would consider putting in the paper-based T-System at that time? Do they tend to go with the electronic T-System or do they say, “Gee, as part of our comprehensive package we’re going to bring in some other solution because it’s integrated in with our main system that we’re putting in’?
Suzy: A lot of people have a long term IT strategy that says they’re going to have a single enterprise vendor. However, the clinical verticals aren’t that well built out on enterprise vendors. They take the overarching clinical premise and try to make that work in the ED. Because the ED is such a unique environment, you don’t necessarily have the ability to take, for example, a consult in the office where you’re doing follow up on hypertension and make that work in the ED. It’s building out those verticals on the large horizontal platform that is a challenge. So, people may say, long term, that they’re going to go to an enterprise vendor, but there’s not really one that leverages the technology to make the work flow better, the clinical care better, that has a content that is really collaborative content, not specific to what that hospital needs. And, I think that’s an overarching strategy. I use Salesforce.com every day. Salesforce works very well for me because they understand my work flow. The technology leverages what I do. And in one of your blogs, somebody said, ‘Getting adoption is difficult with clinicians’. And, it is one of those things that if you don’t leverage their current work flow, it is very difficult to be successful. And you may be successful from an IT perspective with some applications, but we say your core competency in a hospital is patient care. We leverage the current work flow and the processes to make the patient care better, not detract from it. And I think we do that uniquely. And also, our content, because it is dynamic, because we get feedback from users, because we’re constantly updating our content, that makes a huge difference in how people are able to use it and realize the benefits.
David: Suzy, I see on your website, a picture of what looks to me like a motion C5 Mobile Clinical Assistant computer and I have to ask you about that since my friend, Scott Eckert, is the founder of that company. Do you work with Motion Computing and what’s your impression of them?
Suzy: Yes, we do. We have a great relationship with Motion. We have them at a lot of our sites. It’s amazing to me when we first started to implement our electronic record that the mobile devices weren’t what they are now. You’d have to stand right over it. They weren’t as rugged. And the connectivity was not as good. Now we’re finding that, with the Motion devices, we get great connectivity. We have great screen resolution, great screen size, and the images are so much better. Handwriting recognition is so much better. What was really a difficult thing to get people to transition to at one point is now easier and easier so they can basically take that device to the bedside and capture the history, the past family social history, review a physical exam. It’s basically the paper sheet metaphor with a mobile device.
David: You’ve been at this for 12 years, or so. I’m sure you’re not counting, but it’s been a while. If you look ahead five years or so, what would you think might be the biggest difference between where we are today and what you’ll see at that point in time?
Suzy: Well, I think the biggest differences that I see are these quality measure initiatives or value-based purchasing both within CMS and third-party payers. Now, there are those who would say ‘This is payment reform in sheep’s clothing’, and that may not be too far from the truth. It is basically saying, the fee for service, making more money by delivering more services is not what we want to pay for. We want to pay for appropriate care, appropriate utilization. We don’t want to pay for something that you created in the hospital, for example, pneumonia or a decubitus ulcer, or a urinary tract infection. That train has left the station and gained speed every day. I’m actually on a work group with the AMA and HIMSS to say ‘How are we going to get electronic records to report on this so that we have consistent, reproducible, quality data on patients when they present? How are we defining the data? How are we recording the data? How is it extracted?’ Those are all things that are going to happen, are already happening. It increases every day. And so my thinking is that in five years we’re going to be seeing a lot of value-based purchasing and quality measures that must be reported to get reimbursement. So, pay for performance for physicians now is sort of a voluntary thing that you get a little bonus. My thinking is that if you don’t do it, your percentage of Medicare fee schedule is going to drop, or as Aetna’s doing in California, they’re going to say ‘If you are not one of our certified quality providers, you won’t be in network’. And you put the quality stamp on anything and it’s hard for beneficiaries or hospitals or employers to say it’s not good. But, I think it needs to be watched carefully because there are some agendas that could be followed if it’s not implemented and recorded appropriately and well defined. My issue is that they have quality measures that are poorly defined at times. You’re going, ‘how do we make sure that if this is a quality measure, it’s being measured consistently and predictably across, not just a site, but a state, a system. How are we doing that consistently?’
David: There’s a lot of talk about consumerism in health care and I would say the Emergency Department might be the last place that you’d expect to see it, but tell me if I’m wrong there or how that might change. Is consumerism something that is actually coming to the floor in the Emergency Department as well, or are patients still pretty much passive when they come in?
Suzy: No, I think a lot of times what you’ll see is that people will have looked something up before they come in. They’ll have sort of run through the WebMD, ‘What do I think I have’, and will come in with sort of an idea of what they think their plan of care should be. That is something we see in Emergency Departments all the time now. There are still a lot of patients who will acquiesce to whatever the clinicians tell them when they get to the department, but we’re seeing that more and more. And that empowerment is good. It would be nice at some point for us to have good data on cost/benefit ratios to say, ‘We can do this and it will cost you x, we can do this, it’s 2x and your outcome is going to be the same’.
David: I’ve been speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales in Relationship Management at T-System. Suzy, thank you for your time today.
Suzy: Thank you very much, David. I enjoyed it.
How are Emergency Department Doctors Employed?
Hey Suzy, how are Emergency Department doctors employed?
As most of you know EM (Emergency Medicine) is a specialty just like cardiology or surgery. The main difference is that most other specialist have an office practice and admit patients to the hospital. EM does not (except in rare instances in mostly remote areas) admit patients to the hospital. EM does episodic care in the ED (emergency department) they have no office to see patients.
Independent / “Democratic” Group: This is a group of physicians that contract with the hospital to provide physician coverage in the ED. They are not paid by the hospital and contract their billing and billing services. These physicians usually work fee-for-service which means they "eat what they kill" so to speak. This “at risk” model necessitates that their pay is dependent upon seeing patients efficiently and documenting in a comprehensive manner for revenue and liability purposes. In geographically disadvantaged or smaller sites (usually less than 22,000 patients annually) they may also get a "stipend" from the hospital because economic factors and/or volume will not allow the reimbursement to pay a competitive wage to provide services. Absent this stipend the ED physicians would probably seek out a more favorable work environment.
Corporate Physician Group: These include groups like TeamHealth, EmCare, Schumacher Group, Questcare, Keystone, GHEP, etc. These management groups contract with hospitals to staff their ED and employ the doctors that work in the ED's. They provide administrative and management services for the doctors. The doctors can be paid either a straight salary or more frequently they will have an incentive plan that bonuses them based on their productivity.
Hospital Employee: These ED physicians are employed by the hospital. They are paid by the hospital and may or may not have an incentive plan. They are more aligned with the hospital because of their employment status. This status frequently requires relinquishing some of the autonomy associated with private practice. This model is seen most frequently in the Northeastern U.S.
University Faculty: These physicians are faculty at the university and provide coverage as well as supervise residents caring for patients at the university hospital ED. These academic types tend to be mostly straight salary with the exception of a few business savvy university practices implementing a physician incentive plan. Physicians in other ED practice models can also supervise residents, and not all physicians working at university hospitals are necessarily employed by the university (i.e. they may be an independent group or a corporate group contracted to staff the ED).
Now you know the rest of the story...
As most of you know EM (Emergency Medicine) is a specialty just like cardiology or surgery. The main difference is that most other specialist have an office practice and admit patients to the hospital. EM does not (except in rare instances in mostly remote areas) admit patients to the hospital. EM does episodic care in the ED (emergency department) they have no office to see patients.
Independent / “Democratic” Group: This is a group of physicians that contract with the hospital to provide physician coverage in the ED. They are not paid by the hospital and contract their billing and billing services. These physicians usually work fee-for-service which means they "eat what they kill" so to speak. This “at risk” model necessitates that their pay is dependent upon seeing patients efficiently and documenting in a comprehensive manner for revenue and liability purposes. In geographically disadvantaged or smaller sites (usually less than 22,000 patients annually) they may also get a "stipend" from the hospital because economic factors and/or volume will not allow the reimbursement to pay a competitive wage to provide services. Absent this stipend the ED physicians would probably seek out a more favorable work environment.
Corporate Physician Group: These include groups like TeamHealth, EmCare, Schumacher Group, Questcare, Keystone, GHEP, etc. These management groups contract with hospitals to staff their ED and employ the doctors that work in the ED's. They provide administrative and management services for the doctors. The doctors can be paid either a straight salary or more frequently they will have an incentive plan that bonuses them based on their productivity.
Hospital Employee: These ED physicians are employed by the hospital. They are paid by the hospital and may or may not have an incentive plan. They are more aligned with the hospital because of their employment status. This status frequently requires relinquishing some of the autonomy associated with private practice. This model is seen most frequently in the Northeastern U.S.
University Faculty: These physicians are faculty at the university and provide coverage as well as supervise residents caring for patients at the university hospital ED. These academic types tend to be mostly straight salary with the exception of a few business savvy university practices implementing a physician incentive plan. Physicians in other ED practice models can also supervise residents, and not all physicians working at university hospitals are necessarily employed by the university (i.e. they may be an independent group or a corporate group contracted to staff the ED).
Now you know the rest of the story...
Thursday, March 19, 2009
P4P Comments
This is my letter to the editor posted on the Modern Healthcare website:
P4P makes perfect sense, conceptually. Practically it’s not working for a number of reasons.
Most providers are uneducated and uninformed.
As PQRI has evolved I have watched as providers shyly stay on the sidelines as their coding and billing professionals or compliance teams bear the burden of “quality” data extraction, reporting and follow-up.
Why not use the measures to drive protocols or evidence based medicine? I have pushed evidence-based protocols that could be implemented by actually using the quality data to impact patient care and outcomes.
Finally if a measure does not drive decreasing utilization variability (ergo cost variability) or demonstrably improve patient outcomes, what is the point? It is just another layer of complexity and expense. Lets not kid ourselves at some point the expense associated with delivering this “quality” is passed on to the patients. Increasing expense without evidence of better outcomes or decreased utilization variability or decreased cost just doesn’t feel like “Quality” to me.
P4P makes perfect sense, conceptually. Practically it’s not working for a number of reasons.
Most providers are uneducated and uninformed.
- Clinicians have neither the time nor inclination to monitor all of the ever-changing quality initiatives mandated by an ever-increasing number of agencies and payers.
- They are not sure of the measures that apply to their specialty or practice this week, month, or year.
- They are not sure how to report or the implications of reporting (or not reporting).
- They are not sure if a measure applies to them or the hospitals they staff or have admitting privileges
- In the hospital the nurses caring for patients do not know what reportable measures apply to their department or the patients they care for not to mention how it might impact the delivery patient care.
- The quality data is not actionable, there is very little “if this than this”. It appears to be (is) just another task added to a large number of required documentation elements that distract providers from actually delivering quality patient care.
- Many providers look at this as a socially acceptable way to push out payment reform. Who would argue that quality is bad? Certainly not patients or their families. Many providers feel they are on the short end of the stick because thus far the data does not suggest that these measures do anything other than add another layer of administrative hassle and expense.
As PQRI has evolved I have watched as providers shyly stay on the sidelines as their coding and billing professionals or compliance teams bear the burden of “quality” data extraction, reporting and follow-up.
Why not use the measures to drive protocols or evidence based medicine? I have pushed evidence-based protocols that could be implemented by actually using the quality data to impact patient care and outcomes.
Finally if a measure does not drive decreasing utilization variability (ergo cost variability) or demonstrably improve patient outcomes, what is the point? It is just another layer of complexity and expense. Lets not kid ourselves at some point the expense associated with delivering this “quality” is passed on to the patients. Increasing expense without evidence of better outcomes or decreased utilization variability or decreased cost just doesn’t feel like “Quality” to me.
Tuesday, March 10, 2009
4 Tips for Better Business Writing
By David Silverman
After all my posting about what makes for bad business writing, what is my advice for writing well? I'm glad you asked — because that's the subject of the list below.
1. Call to action. The number one thing that separates a memo, report, or PowerPoint from A Tale of Two Cities is a call to action. A novel is to be enjoyed. Business writing is intended to get the audience to do something: invest in a popcorn factory, fill out a kidney donor form, or flee the building in an orderly manner.
Questions to ask: Does my email ask the reader to do anything? If not, why am I sending it?
2. Say it up front. M. Night Shyamalan is paid to surprise folks. We are paid to not surprise our boss, whatever the purpose of your missive, say it in the first line. Mystery and story are great ways to entertain and teach so unless you're looking for a job doing that, spit out why you're writing up front.
Questions to ask: Can the reader tell from the subject line and first sentence what I'm writing about without going further? If not, why are you insisting that they guess?
3. Assume nothing. Does the reader need to know that the project won't succeed if the subway workers strike, that everything depends on a category 5 hurricane not happening in the next 100 years, or that if Lehman goes under the entire firm will implode? Let the reader know what thinking has gone on behind the scenes. And when following up, don't assume everyone remembers everything you've said. If you've got any worries that an acronym, term, or reference is going to elicit a confused moment, just explain it.
Questions to ask: Am I relying on what the audience knows or what I think they ought to know? Am I hiding anything from the reader unintentionally? If so, why do I want to surprise them later on?
4. Do the thinking. How many times have you gotten an email that says, "What are your thoughts?" followed by a forwarded chain of messages. That's the writer saying, "I can't be bothered to explain my reasoning or what I want you to focus on." When you write, make sure you've explained what you're thinking and what you want the reader to spend time on.
Questions to ask: Is my email giving my opinion and options for the reader to respond to? If not, why am I making them try to read my mind?
What makes business writing good or bad in your opinion? Is this something that can be taught, or do you just have to have an instinct for communicating? What are your tips?
After all my posting about what makes for bad business writing, what is my advice for writing well? I'm glad you asked — because that's the subject of the list below.
1. Call to action. The number one thing that separates a memo, report, or PowerPoint from A Tale of Two Cities is a call to action. A novel is to be enjoyed. Business writing is intended to get the audience to do something: invest in a popcorn factory, fill out a kidney donor form, or flee the building in an orderly manner.
Questions to ask: Does my email ask the reader to do anything? If not, why am I sending it?
2. Say it up front. M. Night Shyamalan is paid to surprise folks. We are paid to not surprise our boss, whatever the purpose of your missive, say it in the first line. Mystery and story are great ways to entertain and teach so unless you're looking for a job doing that, spit out why you're writing up front.
Questions to ask: Can the reader tell from the subject line and first sentence what I'm writing about without going further? If not, why are you insisting that they guess?
3. Assume nothing. Does the reader need to know that the project won't succeed if the subway workers strike, that everything depends on a category 5 hurricane not happening in the next 100 years, or that if Lehman goes under the entire firm will implode? Let the reader know what thinking has gone on behind the scenes. And when following up, don't assume everyone remembers everything you've said. If you've got any worries that an acronym, term, or reference is going to elicit a confused moment, just explain it.
Questions to ask: Am I relying on what the audience knows or what I think they ought to know? Am I hiding anything from the reader unintentionally? If so, why do I want to surprise them later on?
4. Do the thinking. How many times have you gotten an email that says, "What are your thoughts?" followed by a forwarded chain of messages. That's the writer saying, "I can't be bothered to explain my reasoning or what I want you to focus on." When you write, make sure you've explained what you're thinking and what you want the reader to spend time on.
Questions to ask: Is my email giving my opinion and options for the reader to respond to? If not, why am I making them try to read my mind?
What makes business writing good or bad in your opinion? Is this something that can be taught, or do you just have to have an instinct for communicating? What are your tips?
Friday, February 13, 2009
Where are the benchmarking data?
This particular post is based on my observations and opinions.
The current theories associated with improving health care seem to have little or no data to establish a current state or target state of health care in the U.S. How will we know things are better if we do not know where we started? How will we know where to focus or how to prioritize our efforts?
Certainly there is more to measure than dollars, deaths, CPT codes and ICD-9 codes. Until the day we demand patient centric health care data that is meaningful, actionable, well defined, standardized, and required we will not achieve evidence based, outcomes based, or patient centric care. Too many patients die because providers think they know better than research and data, their patients are different, sicker, less-compliant, etc… These heretics cannot be concerned with scientific findings that support improved outcomes through treatment plans and protocols!
So at the end of my little rant I guess I am requesting that someone actually care about really changing healthcare by providing meaningful information to those that purchase and consume health care. The fact that health care is organized around its self rather than those whose lives depend on it for more than a pay check seems more than a little counter-productive.
The current theories associated with improving health care seem to have little or no data to establish a current state or target state of health care in the U.S. How will we know things are better if we do not know where we started? How will we know where to focus or how to prioritize our efforts?
Certainly there is more to measure than dollars, deaths, CPT codes and ICD-9 codes. Until the day we demand patient centric health care data that is meaningful, actionable, well defined, standardized, and required we will not achieve evidence based, outcomes based, or patient centric care. Too many patients die because providers think they know better than research and data, their patients are different, sicker, less-compliant, etc… These heretics cannot be concerned with scientific findings that support improved outcomes through treatment plans and protocols!
So at the end of my little rant I guess I am requesting that someone actually care about really changing healthcare by providing meaningful information to those that purchase and consume health care. The fact that health care is organized around its self rather than those whose lives depend on it for more than a pay check seems more than a little counter-productive.
What is POA?
POA stands for "Present on Admission". Without getting in to a lot of regulatory jargon; this basically means that if you get a “reasonably preventable” problem while you are in the hospital CMS (Medicare) is not going to pay for it.
I know what you are going to say “Hey Suzy, who gets to decide what is reasonably preventable?” That would be the payer of course which in this case in CMS.
The dollar figures are significant.
Example:
If a patient is admitted to the hospital with a stroke and a stage III pressure sore is present on admission the DRG payment is $8030.28
If a patient is admitted with a stroke and develops a stage III pressure sore during their hospital stay the payment is $5347.98
What does this mean for the Emergency Department? I have spent significant time questioning CMS officials about this regulation as it states:
· POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
http://www.cms.hhs.gov/HospitalAcqCond/04_Reporting.asp#TopOfPage
But I have been reassured that it does NOT have to be identified before you put in the order for the bed. Time will tell of course.
The main POA diagnoses that will impact the ED are:
· Pressure sores
· Catheter associated urinary tract infections
Most of the others pretty much would have to include a non-ED procedure or would be difficult to demonstrate that it didn’t occur in the hospital. So unless Dr. Garvey decides he’s going to perform your appendectomy on his kitchen table, it is unlikely that you would have a retained surgical foreign body from any place but the hospital.
Let me know if this helps!
Smiles!
-Suzy
The entire list can be found at:
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage
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