Medtech Market Update 2007
Wednesday, January 31, yours truly will be joined by some industry notables in a webinar on the current state of the medical technology industry. The event, produced by MX Magazine and sponsored by medical outsourcing company Avail, will present growth and market size numbers for a variety of hot medical device market segments. You can register for the webinar here. I will be reporting on the diagnostic imaging and health care IT markets.
This time of year is a peak one for new market research studies. And it seems you can't produce a study these days that does not mention “IT communications networks”, or some similar phrase, as a key short term trend. One of the webinar presenters will be talking about point of care diagnostics, a market that's ripe for medical device connectivity. Ventilators is another market with increasing market requirements for medical device connectivity, including both EMR integration and remote surveillance and alarm notification.
If you have any questions after the webinar, just drop me a line or leave a comment here.
Final Thoughts on Optimizing Observation Patient Management
This conference was a great investment of time. (I would include a link to the event so you could see who presented and the topics, but WRG has taken down the link and does not seem to list any past events.) Without exception, the speakers were knowledgeable and informative, conveying lots of good details and experience. This was the fifth year that WRG has produced this conference and a large number of attendees and presenters have participated in the event over the years. The continuity from repeat participation resulted in interesting observations and lessons-learned, based on changes over time.
Regardless of the motivation driving observation unit creation in a hospital, every hospital has observation patients. Because of their undeniable presence among your patient population, they cannot be avoided. Certainly improved management of observation patients has the potential to improve patient flow. But regardless of this potential, observation patients must be managed properly to ensure good outcomes – both clinically for the patient, and financially for the hospital. Recent reimbursement changes have increased the potential for negative financial outcomes with observation patients. A consensus among presenters was that observation patients managed in a dedicated obs unit were significantly better managed than observation patients placed in on-service care units throughout the hospital. Another key learning was that appropriate case management staffing levels are essential (and easily justified if you dig for the data) to avoid loosing your shirt with observation patients.
The practice of emergency medicine, for physicians and nurses, has changed over the past 10 years. The role of observation medicine has grown considerably – many ER docs and nurses still find observation medicine boring and look to swap assignments with others in triage or more acute care areas – but there is a growing acceptance and understanding of the observation role. At the same time, a growing number of hospitals are committed to getting observation right.
It struck me that the level of care delivered (not patient status) in most observation units is very similar to variable acuity units. Obs units tend to have a higher nurse to patient ratio than med surg, but less than the ratio in the ED. These specialized units also include patient monitoring capabilities and the observation of some pretty complex therapies like chemotherapy. Many of the same management and implementation challenges exist for both obs and variable acuity units – staffing skill mix, admissions requirements, and policies and procedures that are unique in the hospital. Many hospitals feel they lack the patient volumes to clearly justify dedicated obs units, despite patient flow problems. Why not create a unit that provides both observation care and variable acuity nursing?
Another topic that came up at the conference was the discharge lounge. The group reported, “I've never heard of a discharge lounge that worked.” And yet, the reasons described for past failures seemed, to this observer, to be implementation failures rather than an indictment of the concept itself. Creating new types of care delivery units of any kind in hospitals is hard - hence the value of a conference on observation units.
I also noticed at this conference a keen interest in other institution's policies, procedures, templates and guidelines – particularly as it relates to implementing a new policy or procedure at the requesting hospital. This is also a common request on the listservs that I subscribe to, the NPSF and biomed listservs. The delivery of health care is incredibly complex and highly variable from provider to provider. Other institutions' protocols, order sheets, policies and procedures are an interesting read, but their value is directly related to how closely your hospital's operations and environment (including providers and patient population) match those of the other hospital's – an unlikely coincidence in my experience.
There is no substitute for good needs assessment, planning, execution and ongoing active management; there is no “instant” observation unit kit to which a hospital can just add staff and a few hundred square feet to create an effective and profitable observation unit that will run itself. To me this is healthcare's greatest frustration and attraction – it's not easy playing Sherlock Holmes and helping solve Important Problems in the delivery of care, but it is what makes getting up the morning worthwhile.
Oh, by the way, you can buy a CD of all the presentations (except the pre-conference workshops like mine – those were charged for separately) from this conference. Go to this page, and select conference “HW707-01/22/2007 Optimizing Observation Pa, $150.00″ from the drop down.
Day Two – Optimizing Observation Patient Management
Joe Zebrowitz MD, started the day talking about medical necessity and observation status. A big challenge to observation is the different rules for Medicare, Medicaid, and managed care – keeping all these straight is problematic. He presented that the typical attending physician doesn't really know what “observation status” really means. They care about how observation will impact their patients:
- Access to care
- Are concerned about how it may impact their reimbursement, and
- Are oblivious to the impact of observation status on the hospital.
Ensuring that physicians are educated and supportive is key. His data, based on about 16,000 cases reviewed, shows that observation is over used on average 45%. If the ALOS is less than 24 hours, the over use is closer to 35%, and if the ALOS is over 24 hours, the over use is closer to 55%. For every patient that is put in observation inappropriately, you've wiped out $100,000 of hospital revenue.
Proper case management is dependent on both a good process and 100% review of every case. Many hospitals are putting case managers in their EDs to review cases, but many get steered into a social worker role doing complex discharge planning. Process variability is a common theme among many of the presenters at this conference. Joe offered a great approach to reducing variability.
Joe also introduced a new term to the audience, the retrospectoscope, a device that allows the user to look back in time to “improve” decisions made in the past.
Kathy Tyrrell, Case Management Director, Prince William Hospital, talked about a role at their hospital, the bed control ESD case manager. This role assesses the appropriate level of care and appropriate status. Reinforcing the previous presentation, Kathy described a great process, and less than perfect results came from process variability. As a small community hospital, she provided a very realistic approach to improving the observation process.
The last presentation that I caught, was by Chris DeFlitch, MD. He compared and contrasted clinical decision units with observation units. At his hospital, justification for the CDU was based on improved
patient flow. Hershey Medical Center was at 100% capacity, and they
could either board patients in the ED or try an observation unit. They
built an 8 bed unit (Hershey has just under 500 beds overall). Like
many other presenters, DeFlitch reported a heavy emphasis on the tight
protocols and disease specific guidelines.
They had a great foundation;
a bueautiful new space (8 beds, 2 RNs) – but RN hires didn't wan to be an
“inpatient nurese” and they had inconsistent MD buy-in. The size
of the unit and patient volume meant RNs and docs were shared with the ED – the
staff resisted adoption of the obs service. What they learned was that implementing the Clinical Decision Unit was not just a new space and procudures, but a transformational change
that they didn't really address.
Observational medicine is different
and requires a considerably different As an aside, the CDU is now also
used surge capacity, minor emergency crowding and boarders. In addition to these changes, observation patients are also allowed in other units/services. Patients must come in through the ED. If the Internal Medicine attending wants to manage observation patients, that's fine too, but there's oversight to ensure they have the appropriate hour-by-hour focus to ensure that care and disposition progresses in a timely fashion. Emergency Medicine observation patients have an ALOS that's 6 hours shorter than the other services – the important point, of course, being that ALOS is tracked and reported monthly by service. Flitch wrapped up with a great description of how they overcame the inevitable implementation problems.
Day One – Optimizing Observation Patient Management, Afternoon
After lunch, Trevor Lewis, MD, kicked things off with a presentation called, Engineering the Observation Unit. As you might expect from the title, he provided an overview for to create and manage observation units. Starting with unit goals and building support for an obs unit, Lewis detailed many of the issues revolving around staffing these units. Policy and procedures described admission protocols, diagnostic testing and capturing data for optimization. The presentation included a lot of great suggestions for integrating an obs unit into the rest of the hospital”s (and attending physician's) operations.
Introduced as a “reimbursement geek,” Konstantinos Agoritsas, MD, was next up talking about revenue opportunities in the ED with observation care coding. He practices at a SUNY hospital where he works with residents and some of the older staff to educate them on proper coding. The focus was on proper and complete documentation, patient classification issues, and the proper way to code for complete reimbursement. Also presented was an interesting financial model based on a very modest patient volume.
A panel discussion on overcoming observation patient management challenges. The panel included a physician and 2 directors of case management. There were lots of questions and discussion on ensuring observation patient support in the EMR. The expansion of diagnostic services was also implemented to ensure timely testing and patient flow. What followed were a lot of questions about the nitty gritty operation of ops units.
The final presenter for the day was Beth Simms, Network Coordinator, Outpatients in Beds/Observation Care Management, Community Health Network in Indianapolis. Her focus was on the impact of nursing on observation patient management and drug administration. Community Health has 4 hospitals, 2 of which have dedicated observation units and 2 that don't. Community has noted that LOS is shorter in hospitals with dedicated observation units, where staff is experienced in managing observation patients.
Day One – Optimizing Observation Patient Management, Cont.
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.
