Optimizing-Observation-Patient-Management

Next up, a panel discussion on educating physicians to ensure compliance. The panel is all physicians. One of the first questions had to do with physician staffing of the ED and obs unit (from the perspective of the physician group that provides ED and obs coverage for the hospital). A pitfall of ED based observation units is that emergency medicine physicians tend to prefer acute care. Unless the ED doc also has a background in primary care or internal medicine, the typical ED doc doesn't have the mind set for covering observation units. A resulting management issue is that observation patients have better physician reimbursement than ED patients, meaning the docs covering the obs unit will generate more revenue - splitting that revenue fairly among the physicians in the practice is a challenge.

New units need specific criteria for patients that are appropriate (or more typically, excluded) for observation. Also needed is a framework for reviewing cases retrospectively, so medical staff can fine tune their observation unit decision making. The panel also recommended that procedures be developed that center admit/discharge questions around binary unambiguous criteria. A frequent strategy is to assign PAs (physician assistants) to manage the obs patients. The natural tendencies of PAs turns out to be inconsistent with the objective of getting obs patients discharged. PAs tend to lean on the patient's general practitioner who are not focused on discharging. All of the panelists reported that they pulled their PAs off the obs unit and refocused them to the ED.

One of the panelists was an admitted "IT dork", and there was a consensus on the importance of having EMR capabilities so ED docs can easily follow observation patients after they're transferred outside of the ED.

Numerous studies have been done comparing hospital observation units run by internal medicine to ED obs units. The preponderance of the data shows that ED obs provide better patient satisfaction, lower LOS, less morbidity and mortality. At Cleveland Clinic they put CHF patients into the ED obs and cut 2 days off the LOS. The message from these ED docs was, "ED obs does it better."

There was also a lot of discussion on effectively leveraging the ED obs unit and working relationships - and informal agreements - with other consulting and attending physicians. By minimizing the middle of the night phone calls, many physicians will agree to see those patients first thing in the morning. They also discussed proving some physicians with "consulting" opportunities, especially surgeons, neurologist and other specialists. The key is getting those physicians to see your patients in as timely a period as possible.

William Kasdon, MD, talked about observation pathways, focused on where obs units fit in the overall care delivery process, patient selection for obs units and all the documentation and management that's necessary to minimize denials and maximize patient flow. The ALOS (average length of stay) in his ED obs unit is about 14.5 hours. When the amount of emergent medical care required by the patient has been delivered and the level of hotel type care starts to ramp up, patients become candidates for the observation unit. These patients can get out of the ED, and placed in a less clinically intense - and expensive - area because most emergent care has been delivered.

The Ed obs unit can help avoid admissions when census is high, and reduce ALOS improving capacity in crowded emergency departments. Kasdon's talk was focused on having diagnosis-specific pathway improves management and repeatability. They've developed a 3 sheet packet for managing obs patients, including a worksheet (not part of the medical record), standard patient orders (also documents for CMS why patient needs observation - admission criteria and necessity), and patient discharge sheets. The discharge sheet consolidates all the typical things done for a particular patient type, especially medication reconciliation.

Robbin Dick, MD, addressed the topic of "show me the money," talking about coding and documentation on observation patients for both hospital and professional billing. After ensuring there were no coders or payors in the audience, he admitted that he can't imagine why anyone would want to be a coder, given the mixture of encyclopedic knowledge, obscure science and black magic that's seemingly needed to properly code patient encounters. A partial list of the alphabet soup of coding standards was introduced - APC, ICD-9CPT, REV, E, DRG, HCPCS (hicks-picks), CMS 1500, and UB92. The instruction manuals for the CMS 1500 is 78 pages, and the UB92 is 95 pages long.

Also covered were the basic Medicare coding requirements for big 3 diagnoses: chest pain, asthma, and CHF (congestive heart failure). Interestingly, he presented research that that showed two different chest pain diagnoses, one treated in an observation unit and one treated as an inpatient, showed that the obs patients were profitable while the inpatients were not.

Pictured right is the conference meeting room.