We’ve all heard the stereotypes: Other countries have socialized medicine, rationed care, endless lines, and little incentive for innovation. OK, there might be a grain of truth to the wait times. But healthcare in other developed nations is surprisingly varied in its mix of public and private providers, and it yields high-quality outcomes for a far better price than in the U.S. And yes, international innovation is alive and well.

Head-to-head comparisons can only go so far, with many countries using vastly different metrics to measure quality and efficiency. Nevertheless, the examples of bundling, reference pricing, and patient-reported outcomes offer a glimpse of how large-scale initiatives can help improve outcomes and bottom lines in the hospital and beyond.

Just the Facts

Last November, the nonprofit Commonwealth Fund in New York funded an analysis of healthcare data from the Organisation for Economic Co-operation and Development (OECD), which explains just how expensive healthcare is here.

In 2008, the U.S. spent roughly $7,500 per person on healthcare, an astonishing 50% more than the next closest country: Norway, at about $5,000 per person. And yet we lag behind Norway and almost all of our other peers in mortality rates. Cathy Schoen, senior vice president for policy, research, and evaluation at the Commonwealth Fund, says the OECD statistics also say something about how we use hospitals. Compared with its peers, the U.S. actually spends a smaller fraction of money on hospital care. We’re also on the low end of the number of acute-care hospital beds and hospital discharges per 1,000 people, and below average on the typical length of stay for acute care, at about 5.5 days. “So we’re not using the hospital more, and we’re not staying in it longer,” Schoen says. “Nor do we have way more beds, so it’s not an occupancy issue that’s driving this.”

Instead, the numbers suggest that the tests ordered, the drugs prescribed, the devices implanted, and other medical services offered are driving up costs, at least in part. So what can other countries tell us? As policymakers here debate how to bundle more healthcare payments around episodes of care (see “A Bundle of Nerves,” November 2010, p. 1), European countries including Germany and the Netherlands already are using the payment initiative on a national level to create efficiencies around hospital-based care. And they’ve done it with an American innovation: diagnostic-related groups, or DRGs. Bundling around a hip replacement, for example, includes the cost of the implant, the surgeon, and all of the hospital care. “It gives the hospital overall and all of its physicians an incentive to say, ‘If we could buy supplies cheaper, let’s do it,’ ” Schoen says.

An eye-popping 2007 McKinsey & Company study documents the relative cost of hip and knee replacement surgeries for five countries. In 2004, U.S. doctors performed just over half as many hip replacements per 100,000 people as their German counterparts. Yet the cost of each hip prosthetic averaged more than $4,800 per patient in the U.S.—four times higher than the $1,200 cost in Germany and the $1,400 cost in the United Kingdom.

Part of this difference, Schoen says, is due to supply chain management and involving doctors in the decision-making process. Many countries (and a few integrated health systems in the U.S.) are asking surgeons to help select just one or two prosthetic implants, negotiate for bulk volume pricing, and then track the clinical outcomes of those devices to flag poor performers, she says.

Setting the Bar for New Drugs

Drugs are another big-ticket item, and the U.S. pays almost twice as much per capita as the OECD average. To keep their prices lower, Schoen says, many European countries have information systems that track the relative clinical effectiveness of pharmaceuticals. “And they’re using it to inform the way they cover drugs: not to exclude them from the list of what’s covered, but to do something in Europe that’s called reference pricing,” she adds.

Let’s say a new drug costs 50% more than an older one with roughly equivalent efficacy. Under reference pricing, a doctor can still prescribe the new drug, but the patient must pay all or most of the difference. Such benchmarking has fueled an interesting dynamic. “The brand names that are coming in and want to get some market share will price themselves lower, because if they’re priced really high compared to the reference price, the chances are they just won’t ever get a market share,” Schoen says. As a result, drug prices stay lower.

The concept, although discussed in the U.S., has yet to be widely implemented here. A new study in the April issue of the Journal of Managed Care Pharmacy, however, could cause some cash-strapped governments to take a closer look.¹ In the study, the Arkansas State Employee Health Plan used reference pricing for proton-pump inhibitors, using the cost of generic omeprazole as its reference point. Over the 43-month reference-pricing period, net plan costs for the drugs dropped by 49.5% per member per month.

Patient Feedback

A third lesson is that constructive feedback on quality can improve performance, even if no money is attached to outcomes. Like the U.S., Germany is placing a high priority on metrics that evaluate hospital quality. Schoen says the German performance improvement initiative is identifying outliers and providing them with feedback and technical support, but it is not built into the payment system. “They’ve had pretty rapid improvement out of that,” she says, “and I would say we’re learning the same thing in the U.S.”

Initially, Medicare data posted on its Hospital Compare website (www.hospitalcompare.hhs.gov) showed a wide hospital-to-hospital variation in mortality rates for pneumonia, heart attacks, and congestive heart failure. But since then, Schoen says, most outliers on the low end have improved dramatically, even though the only payment incentive was to encourage reporting. In fact, CMS is dropping some core measures from its hospital value-based purchasing program.

Public reporting of quality measures, especially mortality rates, is certainly not without controversy. But Schoen says that if handled properly, disseminating information that suggests a facility’s performance is subpar can tap into the professionalism of its staff and create a strong incentive among them to do better. “That’s something true both internationally and in the U.S.,” she says.

In the U.S., Schoen says, the basic questions asked of patients in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) portion of Medicare’s new VBP system represent a good start. But the experiences of other countries, she says, suggest that patient reporting should be directed more at outcomes, similar to a proposal left out of last year’s healthcare reform bill that would have created a feedback system for patients receiving implantable medical devices.

Even so, hospitals like Dartmouth-Hitchcock Medical Center in Lebanon, N.H., are instituting patient feedback systems on their own, and a National Institutes of Health (NIH) initiative called PROMIS (Patient Reported Outcomes Measurement Information System) is gaining traction. “It’s less blaming, and it’s more informing,” Schoen says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Johnson JT, Neill KK, Davis DA. Five-year examination of utilization and drug cost outcomes associated with benefit design changes including reference pricing for proton pump inhibitors in a state employee health plan. J Manag Care Pharm. 2011;17(3):200-212.

We’ve all heard the stereotypes: Other countries have socialized medicine, rationed care, endless lines, and little incentive for innovation. OK, there might be a grain of truth to the wait times. But healthcare in other developed nations is surprisingly varied in its mix of public and private providers, and it yields high-quality outcomes for a far better price than in the U.S. And yes, international innovation is alive and well.

Head-to-head comparisons can only go so far, with many countries using vastly different metrics to measure quality and efficiency. Nevertheless, the examples of bundling, reference pricing, and patient-reported outcomes offer a glimpse of how large-scale initiatives can help improve outcomes and bottom lines in the hospital and beyond.

Just the Facts

Last November, the nonprofit Commonwealth Fund in New York funded an analysis of healthcare data from the Organisation for Economic Co-operation and Development (OECD), which explains just how expensive healthcare is here.

In 2008, the U.S. spent roughly $7,500 per person on healthcare, an astonishing 50% more than the next closest country: Norway, at about $5,000 per person. And yet we lag behind Norway and almost all of our other peers in mortality rates. Cathy Schoen, senior vice president for policy, research, and evaluation at the Commonwealth Fund, says the OECD statistics also say something about how we use hospitals. Compared with its peers, the U.S. actually spends a smaller fraction of money on hospital care. We’re also on the low end of the number of acute-care hospital beds and hospital discharges per 1,000 people, and below average on the typical length of stay for acute care, at about 5.5 days. “So we’re not using the hospital more, and we’re not staying in it longer,” Schoen says. “Nor do we have way more beds, so it’s not an occupancy issue that’s driving this.”

Instead, the numbers suggest that the tests ordered, the drugs prescribed, the devices implanted, and other medical services offered are driving up costs, at least in part. So what can other countries tell us? As policymakers here debate how to bundle more healthcare payments around episodes of care (see “A Bundle of Nerves,” November 2010, p. 1), European countries including Germany and the Netherlands already are using the payment initiative on a national level to create efficiencies around hospital-based care. And they’ve done it with an American innovation: diagnostic-related groups, or DRGs. Bundling around a hip replacement, for example, includes the cost of the implant, the surgeon, and all of the hospital care. “It gives the hospital overall and all of its physicians an incentive to say, ‘If we could buy supplies cheaper, let’s do it,’ ” Schoen says.

An eye-popping 2007 McKinsey & Company study documents the relative cost of hip and knee replacement surgeries for five countries. In 2004, U.S. doctors performed just over half as many hip replacements per 100,000 people as their German counterparts. Yet the cost of each hip prosthetic averaged more than $4,800 per patient in the U.S.—four times higher than the $1,200 cost in Germany and the $1,400 cost in the United Kingdom.

Part of this difference, Schoen says, is due to supply chain management and involving doctors in the decision-making process. Many countries (and a few integrated health systems in the U.S.) are asking surgeons to help select just one or two prosthetic implants, negotiate for bulk volume pricing, and then track the clinical outcomes of those devices to flag poor performers, she says.

Setting the Bar for New Drugs

Drugs are another big-ticket item, and the U.S. pays almost twice as much per capita as the OECD average. To keep their prices lower, Schoen says, many European countries have information systems that track the relative clinical effectiveness of pharmaceuticals. “And they’re using it to inform the way they cover drugs: not to exclude them from the list of what’s covered, but to do something in Europe that’s called reference pricing,” she adds.

Let’s say a new drug costs 50% more than an older one with roughly equivalent efficacy. Under reference pricing, a doctor can still prescribe the new drug, but the patient must pay all or most of the difference. Such benchmarking has fueled an interesting dynamic. “The brand names that are coming in and want to get some market share will price themselves lower, because if they’re priced really high compared to the reference price, the chances are they just won’t ever get a market share,” Schoen says. As a result, drug prices stay lower.

The concept, although discussed in the U.S., has yet to be widely implemented here. A new study in the April issue of the Journal of Managed Care Pharmacy, however, could cause some cash-strapped governments to take a closer look.¹ In the study, the Arkansas State Employee Health Plan used reference pricing for proton-pump inhibitors, using the cost of generic omeprazole as its reference point. Over the 43-month reference-pricing period, net plan costs for the drugs dropped by 49.5% per member per month.

Patient Feedback

A third lesson is that constructive feedback on quality can improve performance, even if no money is attached to outcomes. Like the U.S., Germany is placing a high priority on metrics that evaluate hospital quality. Schoen says the German performance improvement initiative is identifying outliers and providing them with feedback and technical support, but it is not built into the payment system. “They’ve had pretty rapid improvement out of that,” she says, “and I would say we’re learning the same thing in the U.S.”

Initially, Medicare data posted on its Hospital Compare website (www.hospitalcompare.hhs.gov) showed a wide hospital-to-hospital variation in mortality rates for pneumonia, heart attacks, and congestive heart failure. But since then, Schoen says, most outliers on the low end have improved dramatically, even though the only payment incentive was to encourage reporting. In fact, CMS is dropping some core measures from its hospital value-based purchasing program.

Public reporting of quality measures, especially mortality rates, is certainly not without controversy. But Schoen says that if handled properly, disseminating information that suggests a facility’s performance is subpar can tap into the professionalism of its staff and create a strong incentive among them to do better. “That’s something true both internationally and in the U.S.,” she says.

In the U.S., Schoen says, the basic questions asked of patients in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) portion of Medicare’s new VBP system represent a good start. But the experiences of other countries, she says, suggest that patient reporting should be directed more at outcomes, similar to a proposal left out of last year’s healthcare reform bill that would have created a feedback system for patients receiving implantable medical devices.

Even so, hospitals like Dartmouth-Hitchcock Medical Center in Lebanon, N.H., are instituting patient feedback systems on their own, and a National Institutes of Health (NIH) initiative called PROMIS (Patient Reported Outcomes Measurement Information System) is gaining traction. “It’s less blaming, and it’s more informing,” Schoen says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Johnson JT, Neill KK, Davis DA. Five-year examination of utilization and drug cost outcomes associated with benefit design changes including reference pricing for proton pump inhibitors in a state employee health plan. J Manag Care Pharm. 2011;17(3):200-212.

We’ve all heard the stereotypes: Other countries have socialized medicine, rationed care, endless lines, and little incentive for innovation. OK, there might be a grain of truth to the wait times. But healthcare in other developed nations is surprisingly varied in its mix of public and private providers, and it yields high-quality outcomes for a far better price than in the U.S. And yes, international innovation is alive and well.

Head-to-head comparisons can only go so far, with many countries using vastly different metrics to measure quality and efficiency. Nevertheless, the examples of bundling, reference pricing, and patient-reported outcomes offer a glimpse of how large-scale initiatives can help improve outcomes and bottom lines in the hospital and beyond.

Just the Facts

Last November, the nonprofit Commonwealth Fund in New York funded an analysis of healthcare data from the Organisation for Economic Co-operation and Development (OECD), which explains just how expensive healthcare is here.

In 2008, the U.S. spent roughly $7,500 per person on healthcare, an astonishing 50% more than the next closest country: Norway, at about $5,000 per person. And yet we lag behind Norway and almost all of our other peers in mortality rates. Cathy Schoen, senior vice president for policy, research, and evaluation at the Commonwealth Fund, says the OECD statistics also say something about how we use hospitals. Compared with its peers, the U.S. actually spends a smaller fraction of money on hospital care. We’re also on the low end of the number of acute-care hospital beds and hospital discharges per 1,000 people, and below average on the typical length of stay for acute care, at about 5.5 days. “So we’re not using the hospital more, and we’re not staying in it longer,” Schoen says. “Nor do we have way more beds, so it’s not an occupancy issue that’s driving this.”

Instead, the numbers suggest that the tests ordered, the drugs prescribed, the devices implanted, and other medical services offered are driving up costs, at least in part. So what can other countries tell us? As policymakers here debate how to bundle more healthcare payments around episodes of care (see “A Bundle of Nerves,” November 2010, p. 1), European countries including Germany and the Netherlands already are using the payment initiative on a national level to create efficiencies around hospital-based care. And they’ve done it with an American innovation: diagnostic-related groups, or DRGs. Bundling around a hip replacement, for example, includes the cost of the implant, the surgeon, and all of the hospital care. “It gives the hospital overall and all of its physicians an incentive to say, ‘If we could buy supplies cheaper, let’s do it,’ ” Schoen says.

An eye-popping 2007 McKinsey & Company study documents the relative cost of hip and knee replacement surgeries for five countries. In 2004, U.S. doctors performed just over half as many hip replacements per 100,000 people as their German counterparts. Yet the cost of each hip prosthetic averaged more than $4,800 per patient in the U.S.—four times higher than the $1,200 cost in Germany and the $1,400 cost in the United Kingdom.

Part of this difference, Schoen says, is due to supply chain management and involving doctors in the decision-making process. Many countries (and a few integrated health systems in the U.S.) are asking surgeons to help select just one or two prosthetic implants, negotiate for bulk volume pricing, and then track the clinical outcomes of those devices to flag poor performers, she says.

Setting the Bar for New Drugs

Drugs are another big-ticket item, and the U.S. pays almost twice as much per capita as the OECD average. To keep their prices lower, Schoen says, many European countries have information systems that track the relative clinical effectiveness of pharmaceuticals. “And they’re using it to inform the way they cover drugs: not to exclude them from the list of what’s covered, but to do something in Europe that’s called reference pricing,” she adds.

Let’s say a new drug costs 50% more than an older one with roughly equivalent efficacy. Under reference pricing, a doctor can still prescribe the new drug, but the patient must pay all or most of the difference. Such benchmarking has fueled an interesting dynamic. “The brand names that are coming in and want to get some market share will price themselves lower, because if they’re priced really high compared to the reference price, the chances are they just won’t ever get a market share,” Schoen says. As a result, drug prices stay lower.

The concept, although discussed in the U.S., has yet to be widely implemented here. A new study in the April issue of the Journal of Managed Care Pharmacy, however, could cause some cash-strapped governments to take a closer look.¹ In the study, the Arkansas State Employee Health Plan used reference pricing for proton-pump inhibitors, using the cost of generic omeprazole as its reference point. Over the 43-month reference-pricing period, net plan costs for the drugs dropped by 49.5% per member per month.

Patient Feedback

A third lesson is that constructive feedback on quality can improve performance, even if no money is attached to outcomes. Like the U.S., Germany is placing a high priority on metrics that evaluate hospital quality. Schoen says the German performance improvement initiative is identifying outliers and providing them with feedback and technical support, but it is not built into the payment system. “They’ve had pretty rapid improvement out of that,” she says, “and I would say we’re learning the same thing in the U.S.”

Initially, Medicare data posted on its Hospital Compare website (www.hospitalcompare.hhs.gov) showed a wide hospital-to-hospital variation in mortality rates for pneumonia, heart attacks, and congestive heart failure. But since then, Schoen says, most outliers on the low end have improved dramatically, even though the only payment incentive was to encourage reporting. In fact, CMS is dropping some core measures from its hospital value-based purchasing program.

Public reporting of quality measures, especially mortality rates, is certainly not without controversy. But Schoen says that if handled properly, disseminating information that suggests a facility’s performance is subpar can tap into the professionalism of its staff and create a strong incentive among them to do better. “That’s something true both internationally and in the U.S.,” she says.

In the U.S., Schoen says, the basic questions asked of patients in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) portion of Medicare’s new VBP system represent a good start. But the experiences of other countries, she says, suggest that patient reporting should be directed more at outcomes, similar to a proposal left out of last year’s healthcare reform bill that would have created a feedback system for patients receiving implantable medical devices.

Even so, hospitals like Dartmouth-Hitchcock Medical Center in Lebanon, N.H., are instituting patient feedback systems on their own, and a National Institutes of Health (NIH) initiative called PROMIS (Patient Reported Outcomes Measurement Information System) is gaining traction. “It’s less blaming, and it’s more informing,” Schoen says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Johnson JT, Neill KK, Davis DA. Five-year examination of utilization and drug cost outcomes associated with benefit design changes including reference pricing for proton pump inhibitors in a state employee health plan. J Manag Care Pharm. 2011;17(3):200-212.

The Medical University of South Carolina (MUSC) in Charleston hasn’t solved the issue of care transitions for the indigent, “but we have thought about it a lot,” says Neal Axon, MD, MSCR, FHM, assistant professor in the Division of Hospital Medicine at MUSC. The hospital is experimenting with quality-improvement (QI) techniques learned through participation in SHM’s Project BOOST.

“The first principle I try to teach residents is that a good discharge for a patient without insurance is the same as a good discharge for a patient with insurance,” Dr. Axon says. “Many of the same principles apply.”

If the care plan fails to address basic needs of indigent patients, including access to housing, primary care, and affordable medications, that patient won’t be able to focus on their medical needs.

Affiliated primary-care clinics already see a high percentage of indigent patients, Dr. Axon says, so there might be some pushback when the hospital team attempts a new referral. “We have tried to distinguish between care that needs to be done in the first week or so after discharge versus ongoing follow-up,” he explains. “We have negotiated with the clinic so that patients can come back here for one or two visits for urgent follow-up care without being entered into the [outpatient] system permanently. We are also blessed to have federally qualified health centers in the Charleston area. We have cordial relationships with those clinics, even if it’s not as well-integrated as I might wish.”

Another service that can be helpful with care transitions for uninsured patients is a 14-bed transitional-care unit on the hospital campus. “It provides rehabilitation and long-term care for the small numbers of chronically ill patients with long-term disabilities who don’t qualify for Medicaid or Medicare and can’t be placed elsewhere,” he says. “We’re able to care for these patients in a less costly way on the unit, rather than leaving them in an acute-care bed.” The hospital, he adds, views the unit as a cost-avoidance measure.

Some have been on the unit for months; others do much better than expected and go home. “It’s always gratifying when patients come back to the hospital to visit and thank us for the care they received,” he says.

Larry Beresford is a freelance writer based in California.

The Medical University of South Carolina (MUSC) in Charleston hasn’t solved the issue of care transitions for the indigent, “but we have thought about it a lot,” says Neal Axon, MD, MSCR, FHM, assistant professor in the Division of Hospital Medicine at MUSC. The hospital is experimenting with quality-improvement (QI) techniques learned through participation in SHM’s Project BOOST.

“The first principle I try to teach residents is that a good discharge for a patient without insurance is the same as a good discharge for a patient with insurance,” Dr. Axon says. “Many of the same principles apply.”

If the care plan fails to address basic needs of indigent patients, including access to housing, primary care, and affordable medications, that patient won’t be able to focus on their medical needs.

Affiliated primary-care clinics already see a high percentage of indigent patients, Dr. Axon says, so there might be some pushback when the hospital team attempts a new referral. “We have tried to distinguish between care that needs to be done in the first week or so after discharge versus ongoing follow-up,” he explains. “We have negotiated with the clinic so that patients can come back here for one or two visits for urgent follow-up care without being entered into the [outpatient] system permanently. We are also blessed to have federally qualified health centers in the Charleston area. We have cordial relationships with those clinics, even if it’s not as well-integrated as I might wish.”

Another service that can be helpful with care transitions for uninsured patients is a 14-bed transitional-care unit on the hospital campus. “It provides rehabilitation and long-term care for the small numbers of chronically ill patients with long-term disabilities who don’t qualify for Medicaid or Medicare and can’t be placed elsewhere,” he says. “We’re able to care for these patients in a less costly way on the unit, rather than leaving them in an acute-care bed.” The hospital, he adds, views the unit as a cost-avoidance measure.

Some have been on the unit for months; others do much better than expected and go home. “It’s always gratifying when patients come back to the hospital to visit and thank us for the care they received,” he says.

Larry Beresford is a freelance writer based in California.

The Medical University of South Carolina (MUSC) in Charleston hasn’t solved the issue of care transitions for the indigent, “but we have thought about it a lot,” says Neal Axon, MD, MSCR, FHM, assistant professor in the Division of Hospital Medicine at MUSC. The hospital is experimenting with quality-improvement (QI) techniques learned through participation in SHM’s Project BOOST.

“The first principle I try to teach residents is that a good discharge for a patient without insurance is the same as a good discharge for a patient with insurance,” Dr. Axon says. “Many of the same principles apply.”

If the care plan fails to address basic needs of indigent patients, including access to housing, primary care, and affordable medications, that patient won’t be able to focus on their medical needs.

Affiliated primary-care clinics already see a high percentage of indigent patients, Dr. Axon says, so there might be some pushback when the hospital team attempts a new referral. “We have tried to distinguish between care that needs to be done in the first week or so after discharge versus ongoing follow-up,” he explains. “We have negotiated with the clinic so that patients can come back here for one or two visits for urgent follow-up care without being entered into the [outpatient] system permanently. We are also blessed to have federally qualified health centers in the Charleston area. We have cordial relationships with those clinics, even if it’s not as well-integrated as I might wish.”

Another service that can be helpful with care transitions for uninsured patients is a 14-bed transitional-care unit on the hospital campus. “It provides rehabilitation and long-term care for the small numbers of chronically ill patients with long-term disabilities who don’t qualify for Medicaid or Medicare and can’t be placed elsewhere,” he says. “We’re able to care for these patients in a less costly way on the unit, rather than leaving them in an acute-care bed.” The hospital, he adds, views the unit as a cost-avoidance measure.

Some have been on the unit for months; others do much better than expected and go home. “It’s always gratifying when patients come back to the hospital to visit and thank us for the care they received,” he says.

Larry Beresford is a freelance writer based in California.

The halls are quiet, the lights dimmed, the incessant ringing of telephones has fallen silent, patients slumber in their rooms, nurses sit and chart, waiting for the inevitable patient call light to glow once again. Then it happens: the overhead announcement that slices through the night like a knife.

“Code blue, code blue!”

As the code team scurries to the room, they start the protocols. However, they are waiting for someone—the conductor of the symphony, if you will. Who will answer the call? Who will whisk down the hall to take the podium? Will that patient’s primary-care physician (PCP) come? The cardiologist, maybe the pulmonologist?

No, there is one person who walks the halls at night when all others are asleep (even the ED doctors, though awake, are consumed by crowded emergency rooms and cannot help). This person is the nocturnist.

What is a nocturnist, you ask? Well, among the many titles, job descriptions, and opportunities that being a hospitalist can entail, being a nocturnist is the one that shines in the dark of night when everyone else is fast asleep. A nocturnist is a hospitalist who works the night shift. As a resident, you might have nightmares about the many nights you’ve worked, the assembly line of patients, procedures, and cross-cover calls you’ve processed.

Nocturnists are the lone wolves of the night. They wear many hats and encounter a milieu of incessant admissions, more cross-cover calls than you can swing at, more grumpy, sleepy consultant phone exchanges than you would like, and endure the chronic fatigue of a person 20 years older than their actual age. But deep down in the muck of it all, there is something about the night shift that keeps a nocturnist coming back night after night.

Nocturnist in Charge

Working as a nocturnist is the last, purest form of practicing medicine. This position affords you the perfect opportunity to get back to the patient-doctor relationship because you are not rounding on other patients, juggling staff meetings, or battling a slew of other staff pining for your patient (i.e. case workers, physical therapists, consultants, etc.). Therefore, you can spend an adequate amount of time getting to know your patient without feeling rushed.

As far as admissions are concerned, there still are those days when you feel you need more hours in a day and two extra hands to take on the flood, but as the physician in charge, you have the ability to better triage these patients and defer to a specialist if needed. It’s not like those residency days of admitting whatever they call you for.

In addition, you have the opportunity to really hone your medical skills and procedural skills, because you are the specialist at 3 a.m. There will be times when you have to make decisions without the luxury of an immediate consultation; that has its pros and cons, but it definitely makes for an exciting Friday night. Consequently, you usually are the first point of contact for the nursing staff at night, so you have the ability to formulate relationships with nurses like no other physician can, because you are there with them, side by side, handling all the emergent (and often nonemergent) cross-cover calls. The nurses learn to trust you and you them, and there is a sense of camaraderie that forms from that trust.

Night-Shift Benefits

If you are still not convinced that the nocturnist world is for you—though you will be able to spend more time and have a more meaningful relationship with patients, nursing staff, and be the hero to every consultant and PCP you allow to sleep through the night—then I must reveal that the real cherry on top is actually green. Since you are working the least desired shift in your HM group, you are somewhat of a rock star. No one wants you to be unhappy, because they really want you to keep working the night shift. It’s evident by the fact that most nocturnists are paid a 10% to 20% shift differential, according to Payscale.com. In layman’s terms, you get paid more money than everyone else.

Another benefit is that nocturnist shifts range from eight to 12 hours; some even allow you to take call from home, so you can find a position that fits your schedule. The average number of monthly shifts usually is fewer than those working the day shift (10 to 14 shifts compared with 14 to 18 shifts) on average.

Depending on what type of hospital you choose (rural or urban, community or academic), you can have a wide range of nightly responsibilities. Some nocturnists perform as many procedures as they like; others choose to perform no procedures. Patient caps might exist on the number of patients you can admit during a shift. And working as a nocturnist can afford you a terrific lifestyle, because there is an a la carte menu of hospitalist groups, shifts, and practice lifestyles to choose from. And everybody in HM knows that everyone is looking for a nocturnist, so the availability of job offers is never a problem.

Nevertheless, with more money and choices comes more responsibility. As a nocturnist, you have to be flexible and creative in order to stay informed, as you will find it challenging to make all the staff meetings. Ask your group to schedule important group meetings early, so that you can stay after your shift and attend. Sometimes you just have to dig in and stay for those later meetings, if need be. (Sleeping in the call room until your next shift makes you somewhat of a martyr.) And remind your medical director to email you any important information you might have missed.

Even though you won’t be around during the day, you must stay abreast of quality initiatives (CHF, AMI, etc.). Beware of charting requirements, which can change from day to day.

If you are looking for an exciting way of life, and the ability to practice pure medicine after residency, you might want to get “into the night” and consider an HM career as a nocturnist. TH

Dr. Cunningham has been a hospitalist since 2004 and a nocturnist the past three years at Hamilton Medical Center, a community hospital in Dalton, Ga., and locum tenens in the Tennessee area.

The halls are quiet, the lights dimmed, the incessant ringing of telephones has fallen silent, patients slumber in their rooms, nurses sit and chart, waiting for the inevitable patient call light to glow once again. Then it happens: the overhead announcement that slices through the night like a knife.

“Code blue, code blue!”

As the code team scurries to the room, they start the protocols. However, they are waiting for someone—the conductor of the symphony, if you will. Who will answer the call? Who will whisk down the hall to take the podium? Will that patient’s primary-care physician (PCP) come? The cardiologist, maybe the pulmonologist?

No, there is one person who walks the halls at night when all others are asleep (even the ED doctors, though awake, are consumed by crowded emergency rooms and cannot help). This person is the nocturnist.

What is a nocturnist, you ask? Well, among the many titles, job descriptions, and opportunities that being a hospitalist can entail, being a nocturnist is the one that shines in the dark of night when everyone else is fast asleep. A nocturnist is a hospitalist who works the night shift. As a resident, you might have nightmares about the many nights you’ve worked, the assembly line of patients, procedures, and cross-cover calls you’ve processed.

Nocturnists are the lone wolves of the night. They wear many hats and encounter a milieu of incessant admissions, more cross-cover calls than you can swing at, more grumpy, sleepy consultant phone exchanges than you would like, and endure the chronic fatigue of a person 20 years older than their actual age. But deep down in the muck of it all, there is something about the night shift that keeps a nocturnist coming back night after night.

Nocturnist in Charge

Working as a nocturnist is the last, purest form of practicing medicine. This position affords you the perfect opportunity to get back to the patient-doctor relationship because you are not rounding on other patients, juggling staff meetings, or battling a slew of other staff pining for your patient (i.e. case workers, physical therapists, consultants, etc.). Therefore, you can spend an adequate amount of time getting to know your patient without feeling rushed.

As far as admissions are concerned, there still are those days when you feel you need more hours in a day and two extra hands to take on the flood, but as the physician in charge, you have the ability to better triage these patients and defer to a specialist if needed. It’s not like those residency days of admitting whatever they call you for.

In addition, you have the opportunity to really hone your medical skills and procedural skills, because you are the specialist at 3 a.m. There will be times when you have to make decisions without the luxury of an immediate consultation; that has its pros and cons, but it definitely makes for an exciting Friday night. Consequently, you usually are the first point of contact for the nursing staff at night, so you have the ability to formulate relationships with nurses like no other physician can, because you are there with them, side by side, handling all the emergent (and often nonemergent) cross-cover calls. The nurses learn to trust you and you them, and there is a sense of camaraderie that forms from that trust.

Night-Shift Benefits

If you are still not convinced that the nocturnist world is for you—though you will be able to spend more time and have a more meaningful relationship with patients, nursing staff, and be the hero to every consultant and PCP you allow to sleep through the night—then I must reveal that the real cherry on top is actually green. Since you are working the least desired shift in your HM group, you are somewhat of a rock star. No one wants you to be unhappy, because they really want you to keep working the night shift. It’s evident by the fact that most nocturnists are paid a 10% to 20% shift differential, according to Payscale.com. In layman’s terms, you get paid more money than everyone else.

Another benefit is that nocturnist shifts range from eight to 12 hours; some even allow you to take call from home, so you can find a position that fits your schedule. The average number of monthly shifts usually is fewer than those working the day shift (10 to 14 shifts compared with 14 to 18 shifts) on average.

Depending on what type of hospital you choose (rural or urban, community or academic), you can have a wide range of nightly responsibilities. Some nocturnists perform as many procedures as they like; others choose to perform no procedures. Patient caps might exist on the number of patients you can admit during a shift. And working as a nocturnist can afford you a terrific lifestyle, because there is an a la carte menu of hospitalist groups, shifts, and practice lifestyles to choose from. And everybody in HM knows that everyone is looking for a nocturnist, so the availability of job offers is never a problem.

Nevertheless, with more money and choices comes more responsibility. As a nocturnist, you have to be flexible and creative in order to stay informed, as you will find it challenging to make all the staff meetings. Ask your group to schedule important group meetings early, so that you can stay after your shift and attend. Sometimes you just have to dig in and stay for those later meetings, if need be. (Sleeping in the call room until your next shift makes you somewhat of a martyr.) And remind your medical director to email you any important information you might have missed.

Even though you won’t be around during the day, you must stay abreast of quality initiatives (CHF, AMI, etc.). Beware of charting requirements, which can change from day to day.

If you are looking for an exciting way of life, and the ability to practice pure medicine after residency, you might want to get “into the night” and consider an HM career as a nocturnist. TH

Dr. Cunningham has been a hospitalist since 2004 and a nocturnist the past three years at Hamilton Medical Center, a community hospital in Dalton, Ga., and locum tenens in the Tennessee area.

The halls are quiet, the lights dimmed, the incessant ringing of telephones has fallen silent, patients slumber in their rooms, nurses sit and chart, waiting for the inevitable patient call light to glow once again. Then it happens: the overhead announcement that slices through the night like a knife.

“Code blue, code blue!”

As the code team scurries to the room, they start the protocols. However, they are waiting for someone—the conductor of the symphony, if you will. Who will answer the call? Who will whisk down the hall to take the podium? Will that patient’s primary-care physician (PCP) come? The cardiologist, maybe the pulmonologist?

No, there is one person who walks the halls at night when all others are asleep (even the ED doctors, though awake, are consumed by crowded emergency rooms and cannot help). This person is the nocturnist.

What is a nocturnist, you ask? Well, among the many titles, job descriptions, and opportunities that being a hospitalist can entail, being a nocturnist is the one that shines in the dark of night when everyone else is fast asleep. A nocturnist is a hospitalist who works the night shift. As a resident, you might have nightmares about the many nights you’ve worked, the assembly line of patients, procedures, and cross-cover calls you’ve processed.

Nocturnists are the lone wolves of the night. They wear many hats and encounter a milieu of incessant admissions, more cross-cover calls than you can swing at, more grumpy, sleepy consultant phone exchanges than you would like, and endure the chronic fatigue of a person 20 years older than their actual age. But deep down in the muck of it all, there is something about the night shift that keeps a nocturnist coming back night after night.

Nocturnist in Charge

Working as a nocturnist is the last, purest form of practicing medicine. This position affords you the perfect opportunity to get back to the patient-doctor relationship because you are not rounding on other patients, juggling staff meetings, or battling a slew of other staff pining for your patient (i.e. case workers, physical therapists, consultants, etc.). Therefore, you can spend an adequate amount of time getting to know your patient without feeling rushed.

As far as admissions are concerned, there still are those days when you feel you need more hours in a day and two extra hands to take on the flood, but as the physician in charge, you have the ability to better triage these patients and defer to a specialist if needed. It’s not like those residency days of admitting whatever they call you for.

In addition, you have the opportunity to really hone your medical skills and procedural skills, because you are the specialist at 3 a.m. There will be times when you have to make decisions without the luxury of an immediate consultation; that has its pros and cons, but it definitely makes for an exciting Friday night. Consequently, you usually are the first point of contact for the nursing staff at night, so you have the ability to formulate relationships with nurses like no other physician can, because you are there with them, side by side, handling all the emergent (and often nonemergent) cross-cover calls. The nurses learn to trust you and you them, and there is a sense of camaraderie that forms from that trust.

Night-Shift Benefits

If you are still not convinced that the nocturnist world is for you—though you will be able to spend more time and have a more meaningful relationship with patients, nursing staff, and be the hero to every consultant and PCP you allow to sleep through the night—then I must reveal that the real cherry on top is actually green. Since you are working the least desired shift in your HM group, you are somewhat of a rock star. No one wants you to be unhappy, because they really want you to keep working the night shift. It’s evident by the fact that most nocturnists are paid a 10% to 20% shift differential, according to Payscale.com. In layman’s terms, you get paid more money than everyone else.

Another benefit is that nocturnist shifts range from eight to 12 hours; some even allow you to take call from home, so you can find a position that fits your schedule. The average number of monthly shifts usually is fewer than those working the day shift (10 to 14 shifts compared with 14 to 18 shifts) on average.

Depending on what type of hospital you choose (rural or urban, community or academic), you can have a wide range of nightly responsibilities. Some nocturnists perform as many procedures as they like; others choose to perform no procedures. Patient caps might exist on the number of patients you can admit during a shift. And working as a nocturnist can afford you a terrific lifestyle, because there is an a la carte menu of hospitalist groups, shifts, and practice lifestyles to choose from. And everybody in HM knows that everyone is looking for a nocturnist, so the availability of job offers is never a problem.

Nevertheless, with more money and choices comes more responsibility. As a nocturnist, you have to be flexible and creative in order to stay informed, as you will find it challenging to make all the staff meetings. Ask your group to schedule important group meetings early, so that you can stay after your shift and attend. Sometimes you just have to dig in and stay for those later meetings, if need be. (Sleeping in the call room until your next shift makes you somewhat of a martyr.) And remind your medical director to email you any important information you might have missed.

Even though you won’t be around during the day, you must stay abreast of quality initiatives (CHF, AMI, etc.). Beware of charting requirements, which can change from day to day.

If you are looking for an exciting way of life, and the ability to practice pure medicine after residency, you might want to get “into the night” and consider an HM career as a nocturnist. TH

Dr. Cunningham has been a hospitalist since 2004 and a nocturnist the past three years at Hamilton Medical Center, a community hospital in Dalton, Ga., and locum tenens in the Tennessee area.

Click here to listen to Dr. Verma

Click here to listen to ISMP President David Cohen

Click here to listen to Dr. Verma

Click here to listen to ISMP President David Cohen

Click here to listen to Dr. Verma

Click here to listen to ISMP President David Cohen

Branding is defined by Merriam-Webster as the promotion of a product or service tied to a particular brand. Most hospitalists say HM has done a good job branding itself as the go-to physician specialty for patient safety and quality-improvement (QI) initiatives.

But labeling the financial support payments that help pay for that service as a subsidy?

“It’s a horrible branding exercise,” says Troy Ahlstrom, MD, SFHM, chief financial officer of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City.

The monies that change hands between hospitals and HM groups have long been known as subsidies, with one consulting group’s marketing materials giving advice on why subsidies are necessary. Hospitalist John Bulger, DO, FACP, FHM, of Geisinger Medical Center in Danville, Pa., says the payments must be viewed the same as financial agreements with other specialties, which rarely are viewed as subsidies.

“I would like to see us move toward more of a discussion of an investment,” Dr. Bulger says. “If you believe like I do that it’s actually a value-added tool that brings a return to the hospital, then we just have to do a better job of figuring … a methodology across the industry to showcase value.”

Todd Nelson, a technical director at the Westchester, Ill.-based Healthcare Financial Management Association, says hospitals value groups that can provide definable progress in core measures tied to patient safety and QI programs. And when it comes to funding those proactive physician groups, hospitals understand there is a cost of doing business.

“From the hospital perspective, they’re looking at it more as an investment,” says Nelson, a former chief financial officer at Iowa’s Grinnell Regional Medical Center. “They’re looking to engage the physicians. … Patient care is more than showing up and taking care of the patients.”

Richard Quinn is a freelance writer based in New Jersey.

Branding is defined by Merriam-Webster as the promotion of a product or service tied to a particular brand. Most hospitalists say HM has done a good job branding itself as the go-to physician specialty for patient safety and quality-improvement (QI) initiatives.

But labeling the financial support payments that help pay for that service as a subsidy?

“It’s a horrible branding exercise,” says Troy Ahlstrom, MD, SFHM, chief financial officer of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City.

The monies that change hands between hospitals and HM groups have long been known as subsidies, with one consulting group’s marketing materials giving advice on why subsidies are necessary. Hospitalist John Bulger, DO, FACP, FHM, of Geisinger Medical Center in Danville, Pa., says the payments must be viewed the same as financial agreements with other specialties, which rarely are viewed as subsidies.

“I would like to see us move toward more of a discussion of an investment,” Dr. Bulger says. “If you believe like I do that it’s actually a value-added tool that brings a return to the hospital, then we just have to do a better job of figuring … a methodology across the industry to showcase value.”

Todd Nelson, a technical director at the Westchester, Ill.-based Healthcare Financial Management Association, says hospitals value groups that can provide definable progress in core measures tied to patient safety and QI programs. And when it comes to funding those proactive physician groups, hospitals understand there is a cost of doing business.

“From the hospital perspective, they’re looking at it more as an investment,” says Nelson, a former chief financial officer at Iowa’s Grinnell Regional Medical Center. “They’re looking to engage the physicians. … Patient care is more than showing up and taking care of the patients.”

Richard Quinn is a freelance writer based in New Jersey.

Branding is defined by Merriam-Webster as the promotion of a product or service tied to a particular brand. Most hospitalists say HM has done a good job branding itself as the go-to physician specialty for patient safety and quality-improvement (QI) initiatives.

But labeling the financial support payments that help pay for that service as a subsidy?

“It’s a horrible branding exercise,” says Troy Ahlstrom, MD, SFHM, chief financial officer of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City.

The monies that change hands between hospitals and HM groups have long been known as subsidies, with one consulting group’s marketing materials giving advice on why subsidies are necessary. Hospitalist John Bulger, DO, FACP, FHM, of Geisinger Medical Center in Danville, Pa., says the payments must be viewed the same as financial agreements with other specialties, which rarely are viewed as subsidies.

“I would like to see us move toward more of a discussion of an investment,” Dr. Bulger says. “If you believe like I do that it’s actually a value-added tool that brings a return to the hospital, then we just have to do a better job of figuring … a methodology across the industry to showcase value.”

Todd Nelson, a technical director at the Westchester, Ill.-based Healthcare Financial Management Association, says hospitals value groups that can provide definable progress in core measures tied to patient safety and QI programs. And when it comes to funding those proactive physician groups, hospitals understand there is a cost of doing business.

“From the hospital perspective, they’re looking at it more as an investment,” says Nelson, a former chief financial officer at Iowa’s Grinnell Regional Medical Center. “They’re looking to engage the physicians. … Patient care is more than showing up and taking care of the patients.”

Richard Quinn is a freelance writer based in New Jersey.

Click here to listen to Dr. Misky

Click here to listen to Jane Brock

Click here to listen to San Francisco General hospitalists Jeff Critchfield and Michelle Schneidermann

Click here to listen to Dr. Misky

Click here to listen to Jane Brock

Click here to listen to San Francisco General hospitalists Jeff Critchfield and Michelle Schneidermann

Click here to listen to Dr. Misky

Click here to listen to Jane Brock

Click here to listen to San Francisco General hospitalists Jeff Critchfield and Michelle Schneidermann

Enter text here

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Hospitalists work in many types of facilities, including academic centers that utilize residents (including interns) in healthcare delivery. Medical and surgical services furnished by a resident within the scope of the training program are covered as provider services and paid by Medicare through direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments; the services of the resident may not be billed or paid for using the Medicare Physician Fee Schedule.

Similarly, the teaching physician is not paid for the resident’s work. The teaching physician is paid for their participation in patient care. In other words, payment is provided to the teaching physician for services that are:

• Furnished by a physician who is not a resident; or
• Furnished by a resident with a teaching physician physically present during the critical or key portion(s) of the service.

Teaching physicians participate in evaluation and management (E/M) services with residents in several ways. Consider the following teaching physician scenarios:

Scenario 1: “Stand-Alone” Service

The resident sees a patient in the morning. The teaching physician independently sees the patient later that same day, performing all required elements to support their own bill (e.g. 99233: subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making). When documenting, the teaching physician can write their own note with or without any of the residents’ information. The attending note “stands alone” in support of the reported visit level. Alternatively, the teaching physician might “link to” the resident note, instead of personally redocumenting the entire service.

Appropriate documentation includes teaching physician notation of the provided critical or key portion(s) of the service and the involvement in patient management. The visit level is based upon the combined documentation, both teaching physician and resident.

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules. Examples:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of the above linkage statements is acceptable, and “more is always better.” The last example best identifies the teaching physician’s involvement in patient management and best supports other regulatory goals and quality initiatives of the current healthcare environment.

Scenario 2: “Supervised” Service

The resident and the teaching physician see the patient at the same time. The teaching physician supervises the resident’s performance of the required service elements or personally performs elements separate from those completed by the resident. Despite personal supervision, the attending still must document their presence during the encounter, performance of the critical or key portion(s) of the service, and involvement in patient management. The visit level is based upon the combined documentation.

Medicare-accepted teaching physician statements associated with this scenario include:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

These generalized statements will be accepted for billing under teaching physician rules. However, documenting patient-specific elements of the assessment and plan unequivocally demonstrates teaching- physician involvement in patient care and the quality of care provided.

Scenario 3: The “Shared” Service

The resident performs a portion or all of the required service elements without teaching-physician presence and documents this service. The teaching physician then independently performs only the critical or key portion(s) of the service and, as appropriate, discusses the case with the resident. As in the other scenarios, the attending documents the presence and performance of the critical or key portion(s) of the service, as well as involvement in patient management. The teaching physician selects the visit level based upon the combined documentation of the teaching physician and resident.

Such Medicare-approved statements for use by teaching physicians under this scenario include:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Regardless of the timing between the attending and the resident encounter represented in each scenario, the teaching physician cannot “link to” a resident note that has not been written. More specifically, if the resident’s note has not been documented at the time the teaching physician writes their note, the teaching physician can’t link to the resident’s note or consider it for billing purposes.

Time-Based Exception

Time-based E/M services (e.g. critical-care services, discharge-day management, prolonged care, etc.) do not follow the same guideline as the standard E/M services, which are selected upon the level of history, exam, and decision-making. Only the billing provider’s time counts toward the reported visit level. This means that the teaching physician must be present for the entire period of time for which the claim is made. Documentation should identify the teaching physician’s total visit time (spent on the unit/floor for inpatient services), including face-to-face time with the patient. Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s reported time. Additionally, time spent “teaching” the resident cannot be attributed to the teaching physician’s visit time.

Student Notes

Per Medicare guidelines, students (medical, nurse practitioner, etc.) can document services in the medical record. However, the teaching physician can only refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician cannot refer to a student’s documentation of physical exam findings or medical decision-making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision-making activities of the service. The teaching physician then selects the visit level and documents service. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Guidelines for Teaching Physicians, Interns, Residents. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed May 6, 2011.
2. Medicare Claims Processing Manual: Chapter 12, Section 100. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2011.
3. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed May 6, 2011.
4. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 279-285.
5. Pohlig, C. Evaluation & Management Services: An Overview. In: Coding for Chest Medicine 2011. Northbrook, IL: American College of Chest Physicians, 2010; 323-330.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists work in many types of facilities, including academic centers that utilize residents (including interns) in healthcare delivery. Medical and surgical services furnished by a resident within the scope of the training program are covered as provider services and paid by Medicare through direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments; the services of the resident may not be billed or paid for using the Medicare Physician Fee Schedule.

Similarly, the teaching physician is not paid for the resident’s work. The teaching physician is paid for their participation in patient care. In other words, payment is provided to the teaching physician for services that are:

• Furnished by a physician who is not a resident; or
• Furnished by a resident with a teaching physician physically present during the critical or key portion(s) of the service.

Teaching physicians participate in evaluation and management (E/M) services with residents in several ways. Consider the following teaching physician scenarios:

Scenario 1: “Stand-Alone” Service

The resident sees a patient in the morning. The teaching physician independently sees the patient later that same day, performing all required elements to support their own bill (e.g. 99233: subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making). When documenting, the teaching physician can write their own note with or without any of the residents’ information. The attending note “stands alone” in support of the reported visit level. Alternatively, the teaching physician might “link to” the resident note, instead of personally redocumenting the entire service.

Appropriate documentation includes teaching physician notation of the provided critical or key portion(s) of the service and the involvement in patient management. The visit level is based upon the combined documentation, both teaching physician and resident.

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules. Examples:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of the above linkage statements is acceptable, and “more is always better.” The last example best identifies the teaching physician’s involvement in patient management and best supports other regulatory goals and quality initiatives of the current healthcare environment.

Scenario 2: “Supervised” Service

The resident and the teaching physician see the patient at the same time. The teaching physician supervises the resident’s performance of the required service elements or personally performs elements separate from those completed by the resident. Despite personal supervision, the attending still must document their presence during the encounter, performance of the critical or key portion(s) of the service, and involvement in patient management. The visit level is based upon the combined documentation.

Medicare-accepted teaching physician statements associated with this scenario include:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

These generalized statements will be accepted for billing under teaching physician rules. However, documenting patient-specific elements of the assessment and plan unequivocally demonstrates teaching- physician involvement in patient care and the quality of care provided.

Scenario 3: The “Shared” Service

The resident performs a portion or all of the required service elements without teaching-physician presence and documents this service. The teaching physician then independently performs only the critical or key portion(s) of the service and, as appropriate, discusses the case with the resident. As in the other scenarios, the attending documents the presence and performance of the critical or key portion(s) of the service, as well as involvement in patient management. The teaching physician selects the visit level based upon the combined documentation of the teaching physician and resident.

Such Medicare-approved statements for use by teaching physicians under this scenario include:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Regardless of the timing between the attending and the resident encounter represented in each scenario, the teaching physician cannot “link to” a resident note that has not been written. More specifically, if the resident’s note has not been documented at the time the teaching physician writes their note, the teaching physician can’t link to the resident’s note or consider it for billing purposes.

Time-Based Exception

Time-based E/M services (e.g. critical-care services, discharge-day management, prolonged care, etc.) do not follow the same guideline as the standard E/M services, which are selected upon the level of history, exam, and decision-making. Only the billing provider’s time counts toward the reported visit level. This means that the teaching physician must be present for the entire period of time for which the claim is made. Documentation should identify the teaching physician’s total visit time (spent on the unit/floor for inpatient services), including face-to-face time with the patient. Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s reported time. Additionally, time spent “teaching” the resident cannot be attributed to the teaching physician’s visit time.

Student Notes

Per Medicare guidelines, students (medical, nurse practitioner, etc.) can document services in the medical record. However, the teaching physician can only refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician cannot refer to a student’s documentation of physical exam findings or medical decision-making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision-making activities of the service. The teaching physician then selects the visit level and documents service. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Guidelines for Teaching Physicians, Interns, Residents. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed May 6, 2011.
2. Medicare Claims Processing Manual: Chapter 12, Section 100. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2011.
3. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed May 6, 2011.
4. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 279-285.
5. Pohlig, C. Evaluation & Management Services: An Overview. In: Coding for Chest Medicine 2011. Northbrook, IL: American College of Chest Physicians, 2010; 323-330.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists work in many types of facilities, including academic centers that utilize residents (including interns) in healthcare delivery. Medical and surgical services furnished by a resident within the scope of the training program are covered as provider services and paid by Medicare through direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments; the services of the resident may not be billed or paid for using the Medicare Physician Fee Schedule.

Similarly, the teaching physician is not paid for the resident’s work. The teaching physician is paid for their participation in patient care. In other words, payment is provided to the teaching physician for services that are:

• Furnished by a physician who is not a resident; or
• Furnished by a resident with a teaching physician physically present during the critical or key portion(s) of the service.

Teaching physicians participate in evaluation and management (E/M) services with residents in several ways. Consider the following teaching physician scenarios:

Scenario 1: “Stand-Alone” Service

The resident sees a patient in the morning. The teaching physician independently sees the patient later that same day, performing all required elements to support their own bill (e.g. 99233: subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making). When documenting, the teaching physician can write their own note with or without any of the residents’ information. The attending note “stands alone” in support of the reported visit level. Alternatively, the teaching physician might “link to” the resident note, instead of personally redocumenting the entire service.

Appropriate documentation includes teaching physician notation of the provided critical or key portion(s) of the service and the involvement in patient management. The visit level is based upon the combined documentation, both teaching physician and resident.

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules. Examples:

• “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of the above linkage statements is acceptable, and “more is always better.” The last example best identifies the teaching physician’s involvement in patient management and best supports other regulatory goals and quality initiatives of the current healthcare environment.

Scenario 2: “Supervised” Service

The resident and the teaching physician see the patient at the same time. The teaching physician supervises the resident’s performance of the required service elements or personally performs elements separate from those completed by the resident. Despite personal supervision, the attending still must document their presence during the encounter, performance of the critical or key portion(s) of the service, and involvement in patient management. The visit level is based upon the combined documentation.

Medicare-accepted teaching physician statements associated with this scenario include:

• “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”

These generalized statements will be accepted for billing under teaching physician rules. However, documenting patient-specific elements of the assessment and plan unequivocally demonstrates teaching- physician involvement in patient care and the quality of care provided.

Scenario 3: The “Shared” Service

The resident performs a portion or all of the required service elements without teaching-physician presence and documents this service. The teaching physician then independently performs only the critical or key portion(s) of the service and, as appropriate, discusses the case with the resident. As in the other scenarios, the attending documents the presence and performance of the critical or key portion(s) of the service, as well as involvement in patient management. The teaching physician selects the visit level based upon the combined documentation of the teaching physician and resident.

Such Medicare-approved statements for use by teaching physicians under this scenario include:

• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Regardless of the timing between the attending and the resident encounter represented in each scenario, the teaching physician cannot “link to” a resident note that has not been written. More specifically, if the resident’s note has not been documented at the time the teaching physician writes their note, the teaching physician can’t link to the resident’s note or consider it for billing purposes.

Time-Based Exception

Time-based E/M services (e.g. critical-care services, discharge-day management, prolonged care, etc.) do not follow the same guideline as the standard E/M services, which are selected upon the level of history, exam, and decision-making. Only the billing provider’s time counts toward the reported visit level. This means that the teaching physician must be present for the entire period of time for which the claim is made. Documentation should identify the teaching physician’s total visit time (spent on the unit/floor for inpatient services), including face-to-face time with the patient. Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s reported time. Additionally, time spent “teaching” the resident cannot be attributed to the teaching physician’s visit time.

Student Notes

Per Medicare guidelines, students (medical, nurse practitioner, etc.) can document services in the medical record. However, the teaching physician can only refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician cannot refer to a student’s documentation of physical exam findings or medical decision-making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision-making activities of the service. The teaching physician then selects the visit level and documents service. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Guidelines for Teaching Physicians, Interns, Residents. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed May 6, 2011.
2. Medicare Claims Processing Manual: Chapter 12, Section 100. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2011.
3. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed May 6, 2011.
4. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 279-285.
5. Pohlig, C. Evaluation & Management Services: An Overview. In: Coding for Chest Medicine 2011. Northbrook, IL: American College of Chest Physicians, 2010; 323-330.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.

A recent “Current Concepts” article in the New England Journal of Medicine (2011;364:749) by a pair of Yale University physicians asserts that the day is close at hand when ultrasound interpretations by clinicians at the patient’s bedside will become as routine in hospital care as the trusty stethoscope. Ultrasound, a noninvasive form of imaging related to oceanographic sonar, has moved beyond its traditional home in radiology to myriad other medical specialties and practice areas. The technology has become smaller, less expensive, and higher in resolution in recent years, the authors note, adding that it has been used on Mount Everest and the international space station, as well as in battlefield situations.

“It’s becoming more accessible, and more training is available to physicians who aren’t radiologists,” says Diane Sliwka, MD, a hospitalist at the University of California at San Francisco (UCSF).

Dr. Sliwka says the NEJM article represents a milestone in the dissemination of bedside ultrasound. She conducts monthly faculty development training in procedural ultrasound at UCSF, workshops at HM and internal-medicine conferences, and training sessions for other hospitals.

The most common uses for bedside, “point of care” ultrasound include guiding procedures, such as thoracentesis and paracentesis, with improved safety over doing such insertions “blind.” Emerging procedural uses include lumbar puncture and arthrocentesis. Diagnostically, bedside ultrasound can provide quick screening and assessment, for example, of fluid buildup around the heart; previously, it could take hours to get the results from a formal heart study.

As with the stethoscope, Dr. Sliwka says, training in its correct use and scope of appropriate bedside practice is essential: “My advice is to learn from the experts at your facility, including the radiologists, critical care, or emergency physicians.” Ultrasound courses are increasing at hospitalist conferences, but space often is limited, and further supervised practice back home is needed.

The next step for hospitalists could be the definition of appropriate scope of practice, training, and competencies for its use. “Creating a niche in this area can be a nice change of pace from our traditional work as hospitalists,” Dr. Sliwka says. —LB

Technology

Video Chat Takes Off for Physicians

A recent study of digital adoption trends found that 7% of U.S. physicians now use video consultations to communicate with patients.

Manhattan Research’s 2011 “Taking the Pulse” survey of 2,000 physicians’ use of technology found that video chat is emerging as a way to consult with patients about nonurgent issues and follow-up questions or with geographically dispersed patients. Psychiatrists and oncologists are more likely to use the new technology. Doctors’ concerns regarding reimbursement, liability, and HIPAA privacy rules remain barriers to adoption.

For more information, visit ManhattanResearch.com/News-and-Events/Press-Releases/physician-patient-online-video-conferencing.—LB

Legal

Positive Outcomes from Full Disclosure of Medical Errors

The University of Michigan Health System’s (UMHS) risk-management model of full disclosure with offer of compensation for medical errors sparked hospitalist Allen Kachalia, MD, JD, of Brigham & Women’s Hospital in Boston to retrospectively study the outcomes of malpractice-claims-related performance before and after UMHS implemented the system in 2001.

Among the results Dr. Kachalia reported in his research abstract plenary at HM10, and subsequently published in Annals of Internal Medicine (2010;153(4):213-221), the mean monthly rate of new claims per 100,000 patient contacts decreased 36% after the full-disclosure model was adopted, while the rate of claims resulting in lawsuits declined by 65%. Claims also were resolved more quickly with the full-disclosure model.

Disclosure of medical error, Dr. Kachalia says, means “if someone is injured by medical care caused by medical error, the physician tells the patient they made the error, how it happened, and, often, what they’ll do to fix it.” An apology is somewhat different, he adds, and there’s no generic script for an apology. “What patients want is sincerity,” he says.

How can hospitalists work with full disclosure? “The general advice most institutions give is that when you want to disclose a medical error, first get your risk-management and patient-safety officers involved. They can help during every step of the process of investigating the event and disclosing,” Dr. Kachalia explains. “Assure patients that you are going to look into their concerns. Then make sure that a thorough investigation is done.”—LB

Practice Management

AMA-MGMA Toolkit Sorts Transitional-Care Software Options

HM practices with physicians in outpatient settings—be they discharge clinics or transitional-care centers—don’t always know how to determine the most useful practice-management software for their needs. So for those not helped by informatics staff, consider the new “Practice Management System Software Directory” from AMA and the Medical Group Management Association (MGMA).

The online repository, which launched in May, is a companion to the “Selecting a Practice Management System” toolkit the joint venture unveiled last fall. While the system is geared toward ambulatory-care settings, Robert Tennant, a senior policy advisor with MGMA, says any HM group with practitioners working on transitional care would find it useful.

Overall, the directory’s goal is to guide providers on how to navigate the increasingly complex world of practice-management options as new guidelines for “meaningful use” are defined, as well as new rules governing electronic claims processing. A new claims standard, known as HIPAA version 5010, is going live Jan. 1, 2012, so Tennant believes the directory is timely.

“It’s very difficult, whether in a practice or a hospital, to know the best software to pick,” he says. “There are plenty of vendors out there telling you they’re the best. There’s no easy way to comparison-shop.”

Now physicians can use the toolkit to measure basic functions. The directory, which will be updated on a rolling basis, will catalogue price range (excluding implementation costs), the number of installed customers, the target market for the product, what year the software was first offered, and whether the vendor also offers an electronic health record (EHR) system. That last point is of particular note to hospitalists as a link between practice management and medical records can help make a practice more efficient, Tennant says.

“What we’ve seen,” he adds, “is those that have that seamless integration between practice-management systems and EHR have higher productivity and higher levels of satisfaction.” —RQ

By The Numbers

$131,564

The average amount of money HM groups received in support per full-time equivalent (FTE) in fiscal year 2010, according to new SHM-MGMA survey data. The data point—the so-called “subsidy”—was first revealed at HM11 in Dallas.

After several years of leveling off at roughly $100,000, some hospitalists say they were surprised to see the figure rise so quickly. The report also shows that 19% of hospitalist practices receive no support, a finding that prompted new SHM President Joseph Li, MD, SFHM, to ask: “Are we looking at two business models or two care models?”—RQ

A recent “Current Concepts” article in the New England Journal of Medicine (2011;364:749) by a pair of Yale University physicians asserts that the day is close at hand when ultrasound interpretations by clinicians at the patient’s bedside will become as routine in hospital care as the trusty stethoscope. Ultrasound, a noninvasive form of imaging related to oceanographic sonar, has moved beyond its traditional home in radiology to myriad other medical specialties and practice areas. The technology has become smaller, less expensive, and higher in resolution in recent years, the authors note, adding that it has been used on Mount Everest and the international space station, as well as in battlefield situations.

“It’s becoming more accessible, and more training is available to physicians who aren’t radiologists,” says Diane Sliwka, MD, a hospitalist at the University of California at San Francisco (UCSF).

Dr. Sliwka says the NEJM article represents a milestone in the dissemination of bedside ultrasound. She conducts monthly faculty development training in procedural ultrasound at UCSF, workshops at HM and internal-medicine conferences, and training sessions for other hospitals.

The most common uses for bedside, “point of care” ultrasound include guiding procedures, such as thoracentesis and paracentesis, with improved safety over doing such insertions “blind.” Emerging procedural uses include lumbar puncture and arthrocentesis. Diagnostically, bedside ultrasound can provide quick screening and assessment, for example, of fluid buildup around the heart; previously, it could take hours to get the results from a formal heart study.

As with the stethoscope, Dr. Sliwka says, training in its correct use and scope of appropriate bedside practice is essential: “My advice is to learn from the experts at your facility, including the radiologists, critical care, or emergency physicians.” Ultrasound courses are increasing at hospitalist conferences, but space often is limited, and further supervised practice back home is needed.

The next step for hospitalists could be the definition of appropriate scope of practice, training, and competencies for its use. “Creating a niche in this area can be a nice change of pace from our traditional work as hospitalists,” Dr. Sliwka says. —LB

Technology

Video Chat Takes Off for Physicians

A recent study of digital adoption trends found that 7% of U.S. physicians now use video consultations to communicate with patients.

Manhattan Research’s 2011 “Taking the Pulse” survey of 2,000 physicians’ use of technology found that video chat is emerging as a way to consult with patients about nonurgent issues and follow-up questions or with geographically dispersed patients. Psychiatrists and oncologists are more likely to use the new technology. Doctors’ concerns regarding reimbursement, liability, and HIPAA privacy rules remain barriers to adoption.

For more information, visit ManhattanResearch.com/News-and-Events/Press-Releases/physician-patient-online-video-conferencing.—LB

Legal

Positive Outcomes from Full Disclosure of Medical Errors

The University of Michigan Health System’s (UMHS) risk-management model of full disclosure with offer of compensation for medical errors sparked hospitalist Allen Kachalia, MD, JD, of Brigham & Women’s Hospital in Boston to retrospectively study the outcomes of malpractice-claims-related performance before and after UMHS implemented the system in 2001.

Among the results Dr. Kachalia reported in his research abstract plenary at HM10, and subsequently published in Annals of Internal Medicine (2010;153(4):213-221), the mean monthly rate of new claims per 100,000 patient contacts decreased 36% after the full-disclosure model was adopted, while the rate of claims resulting in lawsuits declined by 65%. Claims also were resolved more quickly with the full-disclosure model.

Disclosure of medical error, Dr. Kachalia says, means “if someone is injured by medical care caused by medical error, the physician tells the patient they made the error, how it happened, and, often, what they’ll do to fix it.” An apology is somewhat different, he adds, and there’s no generic script for an apology. “What patients want is sincerity,” he says.

How can hospitalists work with full disclosure? “The general advice most institutions give is that when you want to disclose a medical error, first get your risk-management and patient-safety officers involved. They can help during every step of the process of investigating the event and disclosing,” Dr. Kachalia explains. “Assure patients that you are going to look into their concerns. Then make sure that a thorough investigation is done.”—LB

Practice Management

AMA-MGMA Toolkit Sorts Transitional-Care Software Options

HM practices with physicians in outpatient settings—be they discharge clinics or transitional-care centers—don’t always know how to determine the most useful practice-management software for their needs. So for those not helped by informatics staff, consider the new “Practice Management System Software Directory” from AMA and the Medical Group Management Association (MGMA).

The online repository, which launched in May, is a companion to the “Selecting a Practice Management System” toolkit the joint venture unveiled last fall. While the system is geared toward ambulatory-care settings, Robert Tennant, a senior policy advisor with MGMA, says any HM group with practitioners working on transitional care would find it useful.

Overall, the directory’s goal is to guide providers on how to navigate the increasingly complex world of practice-management options as new guidelines for “meaningful use” are defined, as well as new rules governing electronic claims processing. A new claims standard, known as HIPAA version 5010, is going live Jan. 1, 2012, so Tennant believes the directory is timely.

“It’s very difficult, whether in a practice or a hospital, to know the best software to pick,” he says. “There are plenty of vendors out there telling you they’re the best. There’s no easy way to comparison-shop.”

Now physicians can use the toolkit to measure basic functions. The directory, which will be updated on a rolling basis, will catalogue price range (excluding implementation costs), the number of installed customers, the target market for the product, what year the software was first offered, and whether the vendor also offers an electronic health record (EHR) system. That last point is of particular note to hospitalists as a link between practice management and medical records can help make a practice more efficient, Tennant says.

“What we’ve seen,” he adds, “is those that have that seamless integration between practice-management systems and EHR have higher productivity and higher levels of satisfaction.” —RQ

By The Numbers

$131,564

The average amount of money HM groups received in support per full-time equivalent (FTE) in fiscal year 2010, according to new SHM-MGMA survey data. The data point—the so-called “subsidy”—was first revealed at HM11 in Dallas.

After several years of leveling off at roughly $100,000, some hospitalists say they were surprised to see the figure rise so quickly. The report also shows that 19% of hospitalist practices receive no support, a finding that prompted new SHM President Joseph Li, MD, SFHM, to ask: “Are we looking at two business models or two care models?”—RQ

A recent “Current Concepts” article in the New England Journal of Medicine (2011;364:749) by a pair of Yale University physicians asserts that the day is close at hand when ultrasound interpretations by clinicians at the patient’s bedside will become as routine in hospital care as the trusty stethoscope. Ultrasound, a noninvasive form of imaging related to oceanographic sonar, has moved beyond its traditional home in radiology to myriad other medical specialties and practice areas. The technology has become smaller, less expensive, and higher in resolution in recent years, the authors note, adding that it has been used on Mount Everest and the international space station, as well as in battlefield situations.

“It’s becoming more accessible, and more training is available to physicians who aren’t radiologists,” says Diane Sliwka, MD, a hospitalist at the University of California at San Francisco (UCSF).

Dr. Sliwka says the NEJM article represents a milestone in the dissemination of bedside ultrasound. She conducts monthly faculty development training in procedural ultrasound at UCSF, workshops at HM and internal-medicine conferences, and training sessions for other hospitals.

The most common uses for bedside, “point of care” ultrasound include guiding procedures, such as thoracentesis and paracentesis, with improved safety over doing such insertions “blind.” Emerging procedural uses include lumbar puncture and arthrocentesis. Diagnostically, bedside ultrasound can provide quick screening and assessment, for example, of fluid buildup around the heart; previously, it could take hours to get the results from a formal heart study.

As with the stethoscope, Dr. Sliwka says, training in its correct use and scope of appropriate bedside practice is essential: “My advice is to learn from the experts at your facility, including the radiologists, critical care, or emergency physicians.” Ultrasound courses are increasing at hospitalist conferences, but space often is limited, and further supervised practice back home is needed.

The next step for hospitalists could be the definition of appropriate scope of practice, training, and competencies for its use. “Creating a niche in this area can be a nice change of pace from our traditional work as hospitalists,” Dr. Sliwka says. —LB

Technology

Video Chat Takes Off for Physicians

A recent study of digital adoption trends found that 7% of U.S. physicians now use video consultations to communicate with patients.

Manhattan Research’s 2011 “Taking the Pulse” survey of 2,000 physicians’ use of technology found that video chat is emerging as a way to consult with patients about nonurgent issues and follow-up questions or with geographically dispersed patients. Psychiatrists and oncologists are more likely to use the new technology. Doctors’ concerns regarding reimbursement, liability, and HIPAA privacy rules remain barriers to adoption.

For more information, visit ManhattanResearch.com/News-and-Events/Press-Releases/physician-patient-online-video-conferencing.—LB

Legal

Positive Outcomes from Full Disclosure of Medical Errors

The University of Michigan Health System’s (UMHS) risk-management model of full disclosure with offer of compensation for medical errors sparked hospitalist Allen Kachalia, MD, JD, of Brigham & Women’s Hospital in Boston to retrospectively study the outcomes of malpractice-claims-related performance before and after UMHS implemented the system in 2001.

Among the results Dr. Kachalia reported in his research abstract plenary at HM10, and subsequently published in Annals of Internal Medicine (2010;153(4):213-221), the mean monthly rate of new claims per 100,000 patient contacts decreased 36% after the full-disclosure model was adopted, while the rate of claims resulting in lawsuits declined by 65%. Claims also were resolved more quickly with the full-disclosure model.

Disclosure of medical error, Dr. Kachalia says, means “if someone is injured by medical care caused by medical error, the physician tells the patient they made the error, how it happened, and, often, what they’ll do to fix it.” An apology is somewhat different, he adds, and there’s no generic script for an apology. “What patients want is sincerity,” he says.

How can hospitalists work with full disclosure? “The general advice most institutions give is that when you want to disclose a medical error, first get your risk-management and patient-safety officers involved. They can help during every step of the process of investigating the event and disclosing,” Dr. Kachalia explains. “Assure patients that you are going to look into their concerns. Then make sure that a thorough investigation is done.”—LB

Practice Management

AMA-MGMA Toolkit Sorts Transitional-Care Software Options

HM practices with physicians in outpatient settings—be they discharge clinics or transitional-care centers—don’t always know how to determine the most useful practice-management software for their needs. So for those not helped by informatics staff, consider the new “Practice Management System Software Directory” from AMA and the Medical Group Management Association (MGMA).

The online repository, which launched in May, is a companion to the “Selecting a Practice Management System” toolkit the joint venture unveiled last fall. While the system is geared toward ambulatory-care settings, Robert Tennant, a senior policy advisor with MGMA, says any HM group with practitioners working on transitional care would find it useful.

Overall, the directory’s goal is to guide providers on how to navigate the increasingly complex world of practice-management options as new guidelines for “meaningful use” are defined, as well as new rules governing electronic claims processing. A new claims standard, known as HIPAA version 5010, is going live Jan. 1, 2012, so Tennant believes the directory is timely.

“It’s very difficult, whether in a practice or a hospital, to know the best software to pick,” he says. “There are plenty of vendors out there telling you they’re the best. There’s no easy way to comparison-shop.”

Now physicians can use the toolkit to measure basic functions. The directory, which will be updated on a rolling basis, will catalogue price range (excluding implementation costs), the number of installed customers, the target market for the product, what year the software was first offered, and whether the vendor also offers an electronic health record (EHR) system. That last point is of particular note to hospitalists as a link between practice management and medical records can help make a practice more efficient, Tennant says.

“What we’ve seen,” he adds, “is those that have that seamless integration between practice-management systems and EHR have higher productivity and higher levels of satisfaction.” —RQ

By The Numbers

$131,564

The average amount of money HM groups received in support per full-time equivalent (FTE) in fiscal year 2010, according to new SHM-MGMA survey data. The data point—the so-called “subsidy”—was first revealed at HM11 in Dallas.

After several years of leveling off at roughly $100,000, some hospitalists say they were surprised to see the figure rise so quickly. The report also shows that 19% of hospitalist practices receive no support, a finding that prompted new SHM President Joseph Li, MD, SFHM, to ask: “Are we looking at two business models or two care models?”—RQ

Every May, Mayo Clinic hospitalist Jason Persoff, MD, SFHM, sheds his doctor’s gear, grabs his camera and camcorder, and heads to the Midwest in search of ferocious weather for two weeks. “My wife jokingly calls it my ‘midlife crisis prevention program,’ ” says Dr. Persoff, who works in Jacksonville, Fla.

This year, he put his doctor’s gear back on sooner than he expected.

After 20 years of chasing storms, Dr. Persoff found himself in what might have been considered an inevitable situation: helping people injured in a tornado. When a monstrous twister with winds of more than 200 mph barreled through Joplin, Mo., on May 22, Dr. Persoff was less than a mile from its path. He and a “chase partner,” Robert Balogh, MD, an Oklahoma-based internist and former hospitalist, were able to rush to the scene and assist in the aftermath.

In the moments after the fast-forming storm, Dr. Persoff hoped that the damage wouldn’t be so devastating, despite the first ominous signs he saw along the highway.

“We were dealing with a raining sky of debris,” he says. “There was Styrofoam insulation falling from the sky, papers, there was a Barbie doll in the middle of the road, but I have no idea where that came from. There were trees and twigs and leaves, so I knew that the destruction to Joplin had been significant. But I hoped that it would be very limited.”

As he traveled along another road, he saw two dozen flipped-over semi-trucks.

“There was no decision,” Dr. Balogh says. “We knew right then that the chase was over for us.”

One hospital serving the area, St. John’s Regional Medical Center, was destroyed, its roof ripped off, he learned. At press time, the tornado had killed more than 150 and caused an estimated $3 billion in damage.

Dr. Persoff checked in at the ED of another hospital, Freeman Health System, and offered his help. He spent 10 hours there, first treating trauma patients.

“We were immediately put to work because there were just so many people coming in,” he says. “The initial trauma that came in was pretty fast and furious. If somebody could be saved, and it wasn’t going to require an effort that would jeopardize resources, they did everything they could to save people. They put in chest tubes, ventilated them, [performed] other procedures.

"If somebody was dying and that was pretty obvious, it required us to rethink how we were going to approach things. And I made a diligent effort to help the dying with low doses of pain medication to help them through.”

There were amputations, impalements, eviscerations.

“We had patients who were covered in glass, and by covered I don’t mean they just had glass in their skin—they were covered with it,” he says. “When you’d examine them, there was a risk of your glove getting torn doing an exam.”

Dr. Balogh describes the patient influx as an “absolutely overwhelming” onslaught, with ambulances, cars, and pickup trucks that had rescued strangers on the roadside arriving seemingly nonstop.

It was so frantic, he says, that he was worried “if I even take time to talk to one patient .. I’ve missed the next 15.”

When the patients from St. John’s began to arrive at Freeman, Dr. Persoff treated them, too. He wrote admission orders on 24 patients.

“The patients weren’t able to provide history,” he says. “Some of the medical records fell as far as, I think, Kansas City (160 miles to the north), from the air,” he explains. “So we had no medical records. We had patients who were demented or delirious. We had patients who’d undergone routine procedures, several patients who were postoperative.”

Leaving the hospital, he said, was gut-wrenching.

“I felt like a loser. I felt like I was handing patient-care responsibilities to a completely overtaxed system because I was tired,” he says. “When I started not making good decisions, I knew that I wasn’t helping anybody and it was time for me to step aside. But that was a very hard decision to make.”

Dr. Persoff says he’ll never forget the triage nurse on duty. She was there when he arrived, about 6:30 p.m., and was perfectly orchestrating the trauma care, even though there was no way for any of the hospital staff to know what had become of their own families and homes. And she was still there when he left at 4 a.m., so efficient and fresh it was as if she’d “just come in from having showered.”

“I don’t know what she knew or where her house was or where her family was,” he says. “I just knew that she was there working like there was no tomorrow and doing it in a way that I couldn’t. That was one of the times where I was like, ‘Wow, this is really humbling.’ ”

Dr. Persoff, who writes about his hobby at Stormdoctor.blogspot.com, continued his storm chasing; he even helped provide assistance two days later, after storms near Oklahoma City exacted a human toll that was not nearly as severe. But first, he says, he had to do some soul-searching. After all, he had hoped for a tornado to form in the Joplin area.

“My chase partners and I were talking about how can the rational person want to continue storm-chasing after having seen what we’d seen. And it took me a while to sort of figure out where my own conscience was on this,” he says. “I felt very guilty for having even wanted [a tornado] earlier in the day. Then I also felt like, had the storm not formed where it did, I wouldn’t have been there, my partner Dr. Balogh wouldn’t have been there, and we would not have been able to assist in that disaster.

“So in many ways it was karma. It happened. We were there at a time when Joplin needed some help.”

After the storm, Dr. Persoff received words of thanks from the town.

Jane Culver, a floor nurse with whom he worked, told him via email: “People often say to me, ‘Doctors are just in it for the money, they really don’t really care about me.’ Well, I say they don’t know the Dr. Jason Persoffs of the world. You are a true humanitarian, and the people of Joplin are lucky you were in our midst at our hour of need.”

Stephanie Conrad, whose grandmother Clara had her broken hip cared for by Dr. Persoff, called him “the angel doctor.”

“Thank you so much for using your knowledge, skills, and expertise during this crisis,” Conrad wrote in an email. “It is physicians like you that make a difference in the lives of others. You were truly a blessing that night.” 

Tom Collins is a freelance medical writer based in Florida.

Every May, Mayo Clinic hospitalist Jason Persoff, MD, SFHM, sheds his doctor’s gear, grabs his camera and camcorder, and heads to the Midwest in search of ferocious weather for two weeks. “My wife jokingly calls it my ‘midlife crisis prevention program,’ ” says Dr. Persoff, who works in Jacksonville, Fla.

This year, he put his doctor’s gear back on sooner than he expected.

After 20 years of chasing storms, Dr. Persoff found himself in what might have been considered an inevitable situation: helping people injured in a tornado. When a monstrous twister with winds of more than 200 mph barreled through Joplin, Mo., on May 22, Dr. Persoff was less than a mile from its path. He and a “chase partner,” Robert Balogh, MD, an Oklahoma-based internist and former hospitalist, were able to rush to the scene and assist in the aftermath.

In the moments after the fast-forming storm, Dr. Persoff hoped that the damage wouldn’t be so devastating, despite the first ominous signs he saw along the highway.

“We were dealing with a raining sky of debris,” he says. “There was Styrofoam insulation falling from the sky, papers, there was a Barbie doll in the middle of the road, but I have no idea where that came from. There were trees and twigs and leaves, so I knew that the destruction to Joplin had been significant. But I hoped that it would be very limited.”

As he traveled along another road, he saw two dozen flipped-over semi-trucks.

“There was no decision,” Dr. Balogh says. “We knew right then that the chase was over for us.”

One hospital serving the area, St. John’s Regional Medical Center, was destroyed, its roof ripped off, he learned. At press time, the tornado had killed more than 150 and caused an estimated $3 billion in damage.

Dr. Persoff checked in at the ED of another hospital, Freeman Health System, and offered his help. He spent 10 hours there, first treating trauma patients.

“We were immediately put to work because there were just so many people coming in,” he says. “The initial trauma that came in was pretty fast and furious. If somebody could be saved, and it wasn’t going to require an effort that would jeopardize resources, they did everything they could to save people. They put in chest tubes, ventilated them, [performed] other procedures.

"If somebody was dying and that was pretty obvious, it required us to rethink how we were going to approach things. And I made a diligent effort to help the dying with low doses of pain medication to help them through.”

There were amputations, impalements, eviscerations.

“We had patients who were covered in glass, and by covered I don’t mean they just had glass in their skin—they were covered with it,” he says. “When you’d examine them, there was a risk of your glove getting torn doing an exam.”

Dr. Balogh describes the patient influx as an “absolutely overwhelming” onslaught, with ambulances, cars, and pickup trucks that had rescued strangers on the roadside arriving seemingly nonstop.

It was so frantic, he says, that he was worried “if I even take time to talk to one patient .. I’ve missed the next 15.”

When the patients from St. John’s began to arrive at Freeman, Dr. Persoff treated them, too. He wrote admission orders on 24 patients.

“The patients weren’t able to provide history,” he says. “Some of the medical records fell as far as, I think, Kansas City (160 miles to the north), from the air,” he explains. “So we had no medical records. We had patients who were demented or delirious. We had patients who’d undergone routine procedures, several patients who were postoperative.”

Leaving the hospital, he said, was gut-wrenching.

“I felt like a loser. I felt like I was handing patient-care responsibilities to a completely overtaxed system because I was tired,” he says. “When I started not making good decisions, I knew that I wasn’t helping anybody and it was time for me to step aside. But that was a very hard decision to make.”

Dr. Persoff says he’ll never forget the triage nurse on duty. She was there when he arrived, about 6:30 p.m., and was perfectly orchestrating the trauma care, even though there was no way for any of the hospital staff to know what had become of their own families and homes. And she was still there when he left at 4 a.m., so efficient and fresh it was as if she’d “just come in from having showered.”

“I don’t know what she knew or where her house was or where her family was,” he says. “I just knew that she was there working like there was no tomorrow and doing it in a way that I couldn’t. That was one of the times where I was like, ‘Wow, this is really humbling.’ ”

Dr. Persoff, who writes about his hobby at Stormdoctor.blogspot.com, continued his storm chasing; he even helped provide assistance two days later, after storms near Oklahoma City exacted a human toll that was not nearly as severe. But first, he says, he had to do some soul-searching. After all, he had hoped for a tornado to form in the Joplin area.

“My chase partners and I were talking about how can the rational person want to continue storm-chasing after having seen what we’d seen. And it took me a while to sort of figure out where my own conscience was on this,” he says. “I felt very guilty for having even wanted [a tornado] earlier in the day. Then I also felt like, had the storm not formed where it did, I wouldn’t have been there, my partner Dr. Balogh wouldn’t have been there, and we would not have been able to assist in that disaster.

“So in many ways it was karma. It happened. We were there at a time when Joplin needed some help.”

After the storm, Dr. Persoff received words of thanks from the town.

Jane Culver, a floor nurse with whom he worked, told him via email: “People often say to me, ‘Doctors are just in it for the money, they really don’t really care about me.’ Well, I say they don’t know the Dr. Jason Persoffs of the world. You are a true humanitarian, and the people of Joplin are lucky you were in our midst at our hour of need.”

Stephanie Conrad, whose grandmother Clara had her broken hip cared for by Dr. Persoff, called him “the angel doctor.”

“Thank you so much for using your knowledge, skills, and expertise during this crisis,” Conrad wrote in an email. “It is physicians like you that make a difference in the lives of others. You were truly a blessing that night.” 

Tom Collins is a freelance medical writer based in Florida.

Every May, Mayo Clinic hospitalist Jason Persoff, MD, SFHM, sheds his doctor’s gear, grabs his camera and camcorder, and heads to the Midwest in search of ferocious weather for two weeks. “My wife jokingly calls it my ‘midlife crisis prevention program,’ ” says Dr. Persoff, who works in Jacksonville, Fla.

This year, he put his doctor’s gear back on sooner than he expected.

After 20 years of chasing storms, Dr. Persoff found himself in what might have been considered an inevitable situation: helping people injured in a tornado. When a monstrous twister with winds of more than 200 mph barreled through Joplin, Mo., on May 22, Dr. Persoff was less than a mile from its path. He and a “chase partner,” Robert Balogh, MD, an Oklahoma-based internist and former hospitalist, were able to rush to the scene and assist in the aftermath.

In the moments after the fast-forming storm, Dr. Persoff hoped that the damage wouldn’t be so devastating, despite the first ominous signs he saw along the highway.

“We were dealing with a raining sky of debris,” he says. “There was Styrofoam insulation falling from the sky, papers, there was a Barbie doll in the middle of the road, but I have no idea where that came from. There were trees and twigs and leaves, so I knew that the destruction to Joplin had been significant. But I hoped that it would be very limited.”

As he traveled along another road, he saw two dozen flipped-over semi-trucks.

“There was no decision,” Dr. Balogh says. “We knew right then that the chase was over for us.”

One hospital serving the area, St. John’s Regional Medical Center, was destroyed, its roof ripped off, he learned. At press time, the tornado had killed more than 150 and caused an estimated $3 billion in damage.

Dr. Persoff checked in at the ED of another hospital, Freeman Health System, and offered his help. He spent 10 hours there, first treating trauma patients.

“We were immediately put to work because there were just so many people coming in,” he says. “The initial trauma that came in was pretty fast and furious. If somebody could be saved, and it wasn’t going to require an effort that would jeopardize resources, they did everything they could to save people. They put in chest tubes, ventilated them, [performed] other procedures.

"If somebody was dying and that was pretty obvious, it required us to rethink how we were going to approach things. And I made a diligent effort to help the dying with low doses of pain medication to help them through.”

There were amputations, impalements, eviscerations.

“We had patients who were covered in glass, and by covered I don’t mean they just had glass in their skin—they were covered with it,” he says. “When you’d examine them, there was a risk of your glove getting torn doing an exam.”

Dr. Balogh describes the patient influx as an “absolutely overwhelming” onslaught, with ambulances, cars, and pickup trucks that had rescued strangers on the roadside arriving seemingly nonstop.

It was so frantic, he says, that he was worried “if I even take time to talk to one patient .. I’ve missed the next 15.”

When the patients from St. John’s began to arrive at Freeman, Dr. Persoff treated them, too. He wrote admission orders on 24 patients.

“The patients weren’t able to provide history,” he says. “Some of the medical records fell as far as, I think, Kansas City (160 miles to the north), from the air,” he explains. “So we had no medical records. We had patients who were demented or delirious. We had patients who’d undergone routine procedures, several patients who were postoperative.”

Leaving the hospital, he said, was gut-wrenching.

“I felt like a loser. I felt like I was handing patient-care responsibilities to a completely overtaxed system because I was tired,” he says. “When I started not making good decisions, I knew that I wasn’t helping anybody and it was time for me to step aside. But that was a very hard decision to make.”

Dr. Persoff says he’ll never forget the triage nurse on duty. She was there when he arrived, about 6:30 p.m., and was perfectly orchestrating the trauma care, even though there was no way for any of the hospital staff to know what had become of their own families and homes. And she was still there when he left at 4 a.m., so efficient and fresh it was as if she’d “just come in from having showered.”

“I don’t know what she knew or where her house was or where her family was,” he says. “I just knew that she was there working like there was no tomorrow and doing it in a way that I couldn’t. That was one of the times where I was like, ‘Wow, this is really humbling.’ ”

Dr. Persoff, who writes about his hobby at Stormdoctor.blogspot.com, continued his storm chasing; he even helped provide assistance two days later, after storms near Oklahoma City exacted a human toll that was not nearly as severe. But first, he says, he had to do some soul-searching. After all, he had hoped for a tornado to form in the Joplin area.

“My chase partners and I were talking about how can the rational person want to continue storm-chasing after having seen what we’d seen. And it took me a while to sort of figure out where my own conscience was on this,” he says. “I felt very guilty for having even wanted [a tornado] earlier in the day. Then I also felt like, had the storm not formed where it did, I wouldn’t have been there, my partner Dr. Balogh wouldn’t have been there, and we would not have been able to assist in that disaster.

“So in many ways it was karma. It happened. We were there at a time when Joplin needed some help.”

After the storm, Dr. Persoff received words of thanks from the town.

Jane Culver, a floor nurse with whom he worked, told him via email: “People often say to me, ‘Doctors are just in it for the money, they really don’t really care about me.’ Well, I say they don’t know the Dr. Jason Persoffs of the world. You are a true humanitarian, and the people of Joplin are lucky you were in our midst at our hour of need.”

Stephanie Conrad, whose grandmother Clara had her broken hip cared for by Dr. Persoff, called him “the angel doctor.”

“Thank you so much for using your knowledge, skills, and expertise during this crisis,” Conrad wrote in an email. “It is physicians like you that make a difference in the lives of others. You were truly a blessing that night.” 

Tom Collins is a freelance medical writer based in Florida.