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.
Day One – Optimizing Observation Patient Management
Sharon Mace, MD, Director of the Observation Unit at the Cleveland Clinic kicked off the formal beginning of the conference. They run about 6,000 patients through their 20 bed observation unit at the Cleveland Clinic per year.
Anna Brooks, the Director of Case Management at Sebastian River Medical Center, provided a great overview of the challenges managing hospital observation patients. Her focus is on the process and management (people) issues that surround observation patients. Managing observation patients is a non-trivial task, and Anna provided examples of how they handle observations at Sebatian River. Unlike some hospitals, her hospital does not have a dedicated observation unit, but places observation patients throughout the house. She noted that the Texas Medical Foundation publishes laminated cards for caregivers that serves as a cheat sheet for observation patients – you can download a pdf of the card here. She also recommended this book.
Karen Games is the Regional Utilization Management Director for the California region of Tenet Healthcare. Karen's session focused on case management. Karen's emphasis was on the need for continuous and ongoing focus on the effective management of observation patients. She provided an overview of case management resources and processes needed to effectively manage observation patients. The process for assessing case management departments was particularly interesting. She also mentioned that the pairing of hospitals and physicians is coming down the pike – where the hospital bill and physician bills for the same admission will be compared, and if they don't agree neither will be paid. Karen ended her presentation with specific process and staffing recommendations. Very meaty stuff.
More to come… Pictured right is one of the new mega condos at sunrise.
Optimizing Observation Patient Management
Well, I made it to Las Vegas. My workshop, which focuses on how observation units fit into hospital wide patient flow studies starts in about an hour. Cara Strom has done a great job researching, recruiting and producing the event – and been very patient with me. The following is from the blurb on my session:
My session is the last of three today, which I guess is the primo spot on the schedule since this is a pre-conference workshop and most everyone has come in this afternoon for tomorrow morning.
Most of the presenters are clinicians from places like the Cleveland Clinic, Strong Memorial, Hershey Medical Center and Tenet Healthcare. I will be blogging the conference tomorrow and Wednesday morning, so check back.
New Study Shows Hospital Patient Flow Increasing Problem
Software vendor TeleTracking Technologies and the American College of Emergency Physicians commissioned a survey last month on the state of patient flow in North American hospitals (press release – pdf). The survey is based on interviews with managers, directors and executives, representing over 200 hospitals.
Virtually all the hospitals who participated in the survey felt that patient flow management represents an extremely or somewhat serious challenge (99% of respondents). And 53% felt that patient flow challenges have become more serious in the last 12 months. To illustrate how serious the problem is, 60% of the hospitals reported diverting patients to another hospital in the last year, due to overcrowding problems – and a whopping 23% reported going on divert more than 20 times in that same period.
The most amusing question in the survey: “Is there a standing committee to review patient flow problems?” With 80% answering in the affirmative, it goes to show that some problems require more than a standing committee. The survey does report progress, albeit modest. A full 64% of hospitals report admitting patients from the ER in 2 to 4 hours. The most common admission goal is within 1 hour (35%), but 48% fail to meet their goal more than 50% of the time. The good news is that 54% of hospitals report their ability to move patients from the ED to in-patient status has improved in the last year.
The survey asks about two potential strategies to improve patient flow, adding bed capacity and using “patient flow technology.” With the current hospital building boom, it's not surprising that capacity is a major consideration for a new physical plant – 57% of respondents are considering increased capacity in response to patient flow constraints. Surprisingly, 22% of hospitals reported expanding bed capacity as an option of “last resort” – they must have already built.
Of course, bed capacity is the most expensive option with the longest lead time for improving patient flow – and the result does nothing to improve productivity, management or the actual flow of patients through the hospital. The other option presented in the survey was patient flow technology, bed management and care delivery logistics applications like those offered by TeleTracking and others. When asked if their hospital had implemented patient flow tech to improve overcrowding, 60% reported they had. Of those that said no, 36% reported that they plan to implement such systems in the next 6 to 12 months.
While the hospitals surveyed remain positive about overcoming their patient flow problems (88%), the majority (76%) recognized that a technical solution will have to be complemented with process and staff changes to be effective.
Analysis:
My read of this survey and the market as a whole is that the “easy” solutions to improved patient flow have been done (remember all those committees?) and the resulting improvements have proven inadequate to eliminate the problem – hence the patient flow problems have become more serious for hospitals. The 60% market penetration for patient flow tech is also interesting. Bed management solutions have been around for a long time, and TeleTracking has hundreds of installations. Perhaps in response to the intractability of patient flow problems, patient flow tech solutions are evolving to look past simple bed management to encompass a broader view of the logistics of care delivery – few hospital have fully implemented these more comprehensive solutions.
Besides the solutions mentioned in the survey, there are other approaches that can improve patient flow. A common strategy for opening ED beds are observation units. (I will be presenting a pre-conference workshop on patient flow and observation units next week here.) Another strategy that is gaining adoption is the use of variable acuity nursing units. (More on variable acuity units here, here and here.) One additional reason why patient flow problems are so hard to solve is the impact of attending physicians – abuse of admissions criteria and discharging patients at 6pm rather than 10am are common occurrences that greatly impact flow. The traditional “whatever you say” response hospital administrators give huffy admitting physicians has to end.
You can read a summary of the results here. Pictured right is an emergency department treatment room in Englehart and District Hospital in Ontario.
ED Outpatient Visits – They Cost More Than You Might Think
Medical Care, the journal of the American Public Health Association published a paper this month on the incremental cost to treat non-urgent outpatients in an emergency department setting versus an outpatient clinic. Using California hospital data submitted to the Office of Statewide Health Planning and Development (OSHPD) between 1990 and 1998 the data were used to estimate hospital cost functions, which were then used to test for
economies of scale and to derive estimates of both short- and long-run
marginal costs (excluding the physician expense component).. Hospitals without EDs, or hospitals designated as trauma centers, were excluded from the analysis.
Principal Findings: We found only weak evidence in favor of scale
economies and, in that context, we argue that long-run marginal costs
should be the preferred metric for judging the cost of treating
outpatient ED visitors. We estimate these long-run costs (in 1998
dollars) to be roughly $348 per visit for large urban hospitals, $288
for other urban hospitals, $203 for rural hospitals, and $314 overall.
Conclusions:
Our results suggest that the marginal cost of an outpatient ED visit is
larger than is commonly believed. A key implication of this finding is
that hospital administrators need to think more carefully about their
nonurgent care policies, especially as they pertain to ED operations.
Not included in the study is news that early innovator hospitals are starting to implement lower cost urgent care clinics to treat out patients who present at the ER. These outpatient clinics are typically located in near by professional buildings, outside of the higher cost hospital.
Pictured right is an emergency room shot from Englehart and District Hospital in Ontario, Canada.
Billings Clinic Participates in CMS Telehealth Demonstration Project
The Billings Clinic, Billings, Montana, is participating in a three-year CMS demonstration project, trying to reduce
costs to Medicare. The project seeks to determine whether spending
more money on preventive care and disease management saves money
overall by preventing hospitalizations. The Billings Clinic project is focused on CHF (chronic heart failure) patients. For patients over 65, CHF is the most expensive diagnosis for Medicare.
The telehealth system being used by Billings Clinic is pretty simple:
pressing buttons on his home telephone, pop up on [Jo] Rowland's computer
screen. If Rowland [the lead nurse for Billings Clinic's heart failure disease management program] notices something out of the ordinary, she calls him.
Depending
on what else Martin tells her, Rowland might adjust his medication or
schedule an appointment for him with his physician, Dr. Lynn Otto.
This story resonates with a number of topics that were raised at this week's Healthcare Unbound conference. A critical innovation factor that I mentioned in my presentation at HU, is the availability of proofs to validate marketing claims like improved outcomes or lowered costs. What caught my attention was the low tech way this telehealth application was implemented – basically a phone and IVR application. Payors look at both the general application (here chronic disease management of CHF) and the technology used to provide the telehealth application. So in developing proofs for your solution, be sure to validate both the application and the value of the technology being used. The other thing that jumped out is the high-touch human interaction that the system provides.
“It gives you a sense of knowing somebody cares, knowing somebody's watching out for you,” he said.
Even on Independence Day, a holiday for most people, a nurse called to check up on him.
“It just makes you feel good,” Martin said.
Since joining the project in January, Martin has not been admitted once to the hospital – not bad form someone who's near the top of the nation's heart transplant list for those same seven months.
Pictured right is patient Allen Martin.
