The project was lead by Stephen Matchett, MD, Chair, and Project Sponsor, and included the following team members:

• I/S Applications and Administration
• Clinical Services Administration and leadership
• Respiratory Therapy
• Administrative Planning
• Pharmacy
• Clinical Engineering
• Others invited on as needed basis

The Lehigh Valley system is based on an application from iMDsoft. Device drivers for legacy devices (or devices that do not include connectivity) use serial device drivers written by iMDsoft. Patient context for devices with serial interfaces was done by bed location. [This works fine for an ICU implementation where patients rarely move - connectivity on devices connected to lower acuity patients should establish patient context in the device.] Data was received from devices with built in connectivity (via integrated network support) via HL7 from the device vendor’s HL7 server.

They use HP OpenView to monitor device connectivity as far as the Lantronix terminal server for serial-based devices. Devices with network connections can be monitored by OpenView up to the medical device vendor’s server. The links between the device and the next step (term server or device vendor’s server) is not visible to IT for monitoring. They usually get warning from biomedical engineering when new devices or firm ware upgrades, and test in advance of deployment.

An interesting part of their description of the project includes a test environment. During deployment, this environment was a “simulated ICU” that includes back to back TNICU/MICU beds in test, and four additional beds at remote ends of the ICU. Beds were added until the first twenty eight ICU beds were online. This required continuous coordination with Facilities and Bed Management. As the first 28 bed unit prepared to go live, additional units were subsequently wired & placed in test. This approach offered the following advantages: facilitation of training by department prior to “go live,” and identification and correction of system, device and workflow issues. Once fully deployed, they use spare devices (they’re usually available) to create a test environment as needed.

Surprisingly, they’ve had problems with some vendors getting the data required to develop a serial port device driver.

Christina Roberts, on the IT side, talked about the nursing and clinical engineering relationship. At Lehigh Valley, the IT department facilitates the coordination between nursing and biomedical engineering. The IT department takes calls 24×7 and provides tier 1 support for the aICU (and other clinical information systems). Depending on the problem, they will call biomedical engineering.

According to this story in the New York Times, “More than half the doctors from New York State, New Jersey and
Connecticut who responded to a survey conducted in April by the
American College of Emergency Physicians said that boarding had
increased significantly in recent years.” Boarding is the practice of treating patients in hallways of busy Emergency Departments, frequently while waiting for an in-patient bed to become available.

You can chalk up this survey as another example of the increase in reporting of patient safety and outcomes:

Ms. [Julie] Lloyd [a spokeswoman for the American College of Emergency Physicians] said the survey was the first by her group, or any other she
knew of, to try to assess the number of deaths resulting from boarding.
She said in an e-mail message that a key point in legislation before
Congress “is to collect boarding statistics, which heretofore have
remained the province of the hospitals.”

Public reporting of boarding seems to be in our future, nation wide.

Don't kid yourself, boarded patients have died, in New Jersey and beyond. There are no statistics on this because hospitals don't code the cause of death to reflect the preventable adverse event that killed them like, “death from inattention due to boarding.” Harsh? Perhaps, but this is a long standing problem in which most hospitals still wring their hands and ask, “what can we do?” Here's what they did at Stony Brook hospital:

[Hat tip: FierceHealthcare]

After spending nearly $500,000, a year to implement the system, and training 1,600 employees, the hospital went live.

[Hat tip: iHealthBeat]

Tony Chen at the Hospital Impact blog has a great post on the tsunami of recent deals in health care. These deals are changing the health care industry. Outsiders in the form of private equity investors and insider hospital M&A are gobbling up failing organizations or those weakened by market changes for which they have ineffective responses. Newly recast ventures that are successful will reward effective change which will drive additional change.

The change required is not the simple head count reduction, and trying to figure out how to do the same old thing with fewer people. What is needed are fundamental changes to the way that care is delivered. These are the changes that will reduce length of stay and improve both patient safety and outcomes. Hospitals today are stuck between a rock and hard place - the rock is the inexorable reduction in reimbursement, and the hard place is the increased visibility and transparency surrounding patient safety and outcomes.

Here are a couple quick examples of the change I'm referring to. Almost every hospital boards patients in the emergency department (ED) to a greater or lesser degree. These patients, shuffled off to out of the way halls awaiting admission, are cared for by off-service nurses (ED nurses) at ever worsening - and sometimes hair raising - nurse to patient ratios. A few heretical hospitals have started boarding those patients awaiting beds up on the floors, on their service. Consequently, each nursing unit could have 1 or 2 extra patients - receiving appropriate care (because they're in the appropriate unit) and at a nurse to patient ratio that is only slightly impacted by a couple extra patients. To someone from another industry this makes admirable sense. From my peers, I've heard excuses ranging from “it's jut not done” to “we can't do it because of fire codes (or department of health regs, etc.)”.

The other example is variable acuity care delivery. Hospitals are organized into units that are specialized based on the level of care, nursing vigilance, therapies that can be delivered, and staff training. This regimented organization was used in manufacturing 20 years ago. Like manufacturing in general, manufacturing healthy patients is not a steady state process. Consequently, census in units varies wildly from unit to unit and day to day. Some units are habitually over capacity, and represent the most common patient flow bottleneck found in hospitals - those over capacity units are critical care units with patient monitoring. Variable acuity units are an analog to manufacturing clusters or pods where the physical environment is quickly modified to adjust to new requirements. Rather than transferring patients because of needed patient monitoring, or a more sophisticated therapy, those patients are kept in their unit and those resources are brought to them. Monitoring patients outside traditional monitored units is a growing trend - half of the telemetry transmitters in hospitals are used on non-cardiology patients. Implementing variable acuity care units is not easy; it requires some pretty fundamental changes.

So, how do you accommodate falling reimbursement and demands to improve patient safety and outcomes? The opportunities to improve operations are many, almost as many as the excuses used to avoid substantive change. As private equity and M&A roils the health care industry, smart people will ask the hard questions with increasing fequency, and change will come.

Pictured right, “resistance is futile.”

The California Healthcare Foundation has underwritten a study looking at ambulance diversions across the state. Findings in this phase 1 report showed that state wide emergency departments (EDs) were on divert an average of 10% in 2005. Emergency department closings to ambulances continue to confound hospital administrators. You can read about a recent survey showing patient flow as an increasing problem here.

ED diversions also frustrate policy wonks and consultants due to the almost total absence of public reporting. Certainly hospitals (and their state associations), emergency response districts, along with some local and state governments, know their emergency room diversion statistics - they just aren't publicly available. Even though access to data is improving, organizations like the CHF have to pay to collect much of their data.

As expected, the study finds that ED diversions occur mostly in urban areas. Increasingly districts and hospitals are implementing “no diversion” policies - in other words they simply take the patients that they used to refuse - even though in most cases little or nothing has been done to improve emergency department overcrowding or patient flow.

You can download your version of the first report here.

Since patient flow interests me, all of the patient flow and bed management vendors are on my list to visit. I started with StatCom who officially introduced their new product at this year's show. Their new release is a combination of new architecture upon which they're running current and new applications. According to StatCom CEO Eric Morgan and EVP Ben Sawyer, the new release takes StatCom from a departmental orientation to supporting patient flow and the delivery of care on a new enterprise-level scope. Automation in support of the efficient movement of patients through the care delivery process is the health care equivalent of industrial logistics management - health care may lag 10-15 years in this area, but we can take advantage of concepts, software application design and architecture that have been refined over many years. Obviously, we can't just apply industrial management techniques to health care, but the concepts and processes are readily transferable to the delivery of care. StatCom is keenly aware of this and is drawing heavily on industrial logistics to guide and inform their approach to automating the care delivery process to increase patient velocity through the hospital.

Ken Kiser MD, CEO of MedSphere, is probably the most visible proponent for bringing the open source software model to health care. MedSphere is using the VA's VISTA EMR as the code base for their EMR. Last week MedSphere had two big open source releases. They released server and clinical information system services under a GPL license and another release under a Mozilla variation that they call an MPL license. This is their first big contribution of new features to the code base, that's available to the public. They've reserved some rights like attribution, but there are no license fees. Their business model is based on providing implementation services and ongoing software support and enhancement around their code base.

Ken believes the open source business model is well suited for health care. There are many applications and capabilities that providers would like to have. In a market dominated by large health care IT vendors, new software (what little they actually develop rather than acquire) must be justified by large market opportunities, leaving many market requirements unmet. Open source efforts can fill this gap by providing complete applications or software components that meet those needs that lack the big market potential conventional vendors need to justify new product development. The challenge for the open source business model is to come together into an effective organizing structure to facilitate interoperability, consistency and quality. With this most recent code release, MedSphere hopes to contribute to advancing the open source model. Rusty Lewis, MedSphere's CTO, is leading this effort and MedSphere plans to add dedicated resources to advancing open source software in health care.

Later I came across an RFID vendor I'd never heard of called RadiantWave. Business models in the RTLS space are presently going through considerable transition. Some vendors are moving to become enterprise infrastructure providers, others are moving into the application space. Some RTLS vendors have developed their own technology, while others have OEM'd their technology. RadiantWave is an unusual chimera - they are tag agnostic through an “edgeware” positioning engine that they developed and an enterprise mobile resource management system licensed from Red Prairie. RadiantWave has been working with large health care delivery providers (multi site providers is their sweet spot) by providing an enterprise logistics system and configuring specific applications for providers on top of that enterprise architecture. The result strikes me of an enterprise oriented custom application development business model. I can't decide whether this is an oxymoron or a brilliant business strategy.

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.

• 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.

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.

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.