Patient Safety

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

 

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

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Dr. Whitcomb is chief medical officer of Remedy Partners. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

 

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

---

Dr. Whitcomb is chief medical officer of Remedy Partners. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.

The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.

The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.

How Does Bundled Payment Work?

The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.

Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.

The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.

Hospitalists and BPCI

Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.

Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.

 

Where Will Savings Come From?

Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.¹ As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.

Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.

Conclusion

Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.

In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.

---

Dr. Whitcomb is chief medical officer of Remedy Partners. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

Reference

1. Mechanic R. Post-acute care: the next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

A Yale University research team has described what constitutes a good hospital discharge, based on its analysis of 1,500 discharge summaries from patients with exacerbations of heart failure at 46 hospitals enrolled in TeleMonitoring to Improve Heart Failure Outcomes (TELE-HF), a large multicenter study of patients hospitalized with heart failure.

“We consider a good discharge to be a three-legged stool composed of timeliness, transmission to the right person, and having the right components, as defined by The Joint Commission and the Transitions of Care Consensus Conference,” says co-author Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University.

Historically, discharge summaries were used primarily for billing, but the medical community has not made full use of them as tools for transition or considered what was really needed by the physician who will see the patient next, Dr. Horwitz says. In a previous study at Yale, as many as a third of discharge summaries were never received by a follow-up physician, and only 15% included the patient’s discharge weight—an essential detail for managing their cardiac care.

A second study using the TELE-HF data found that when the quality of the discharge summary was improved, readmissions rates were lower.

“This study tells us for the first time that it is actually worth spending the time and effort to improve discharge communication, and patients do seem to benefit,” Dr. Horwitz says.

Individual physicians should feel empowered by the result to work on system change in their hospitals, she says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

A Yale University research team has described what constitutes a good hospital discharge, based on its analysis of 1,500 discharge summaries from patients with exacerbations of heart failure at 46 hospitals enrolled in TeleMonitoring to Improve Heart Failure Outcomes (TELE-HF), a large multicenter study of patients hospitalized with heart failure.

“We consider a good discharge to be a three-legged stool composed of timeliness, transmission to the right person, and having the right components, as defined by The Joint Commission and the Transitions of Care Consensus Conference,” says co-author Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University.

Historically, discharge summaries were used primarily for billing, but the medical community has not made full use of them as tools for transition or considered what was really needed by the physician who will see the patient next, Dr. Horwitz says. In a previous study at Yale, as many as a third of discharge summaries were never received by a follow-up physician, and only 15% included the patient’s discharge weight—an essential detail for managing their cardiac care.

A second study using the TELE-HF data found that when the quality of the discharge summary was improved, readmissions rates were lower.

“This study tells us for the first time that it is actually worth spending the time and effort to improve discharge communication, and patients do seem to benefit,” Dr. Horwitz says.

Individual physicians should feel empowered by the result to work on system change in their hospitals, she says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

A Yale University research team has described what constitutes a good hospital discharge, based on its analysis of 1,500 discharge summaries from patients with exacerbations of heart failure at 46 hospitals enrolled in TeleMonitoring to Improve Heart Failure Outcomes (TELE-HF), a large multicenter study of patients hospitalized with heart failure.

“We consider a good discharge to be a three-legged stool composed of timeliness, transmission to the right person, and having the right components, as defined by The Joint Commission and the Transitions of Care Consensus Conference,” says co-author Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University.

Historically, discharge summaries were used primarily for billing, but the medical community has not made full use of them as tools for transition or considered what was really needed by the physician who will see the patient next, Dr. Horwitz says. In a previous study at Yale, as many as a third of discharge summaries were never received by a follow-up physician, and only 15% included the patient’s discharge weight—an essential detail for managing their cardiac care.

A second study using the TELE-HF data found that when the quality of the discharge summary was improved, readmissions rates were lower.

“This study tells us for the first time that it is actually worth spending the time and effort to improve discharge communication, and patients do seem to benefit,” Dr. Horwitz says.

Individual physicians should feel empowered by the result to work on system change in their hospitals, she says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

Almost weekly, a white paper, report, journal article, or press release touts a new program, software, or technology system offering to help hospitals improve their readmissions avoidance processes and penalty exposure. Does this new readmissions cottage industry offer value to hospitals?

Some technologies focus on interdisciplinary team communication, with electronic repositories or virtual rounding, automated communications to the PCP, personalized patient instructions booklets, or telecommunications or mobile applications. Others aim to help coordinate patients’ care transitions and providers’ post-discharge outreach, empower patients, increase compliance with discharge instructions, or schedule and coordinate follow-up activities.

An August 16, 2013, blog post at HISTalk identified other technologies and services being employed by advisory panelists’ hospitals to reduce their readmissions, including electronic health record (EHR) vendors, predictive modeling vendors, home-grown analytics reports, decision support, niche software vendors focused on supporting case management, telemonitoring programs, and use of the LACE (length of stay, acuity of admission, co-morbidities, and number of previous ED visits in the last six months) index to identify patients at risk.

“I view these as tools and, like any tool, they can be helpful if they are the right tool for the job, applied correctly,” says Gregory Maynard, MD, MSc, SFHM, clinical professor and chief quality officer at the University of California Davis Medical Center in Sacramento. “In many cases, these tech tools are trying to reproduce virtually what ideally would be done in person—interdisciplinary bedside rounds with the active engagement of the patient.”

Mark V. Williams, MD, FACP, MHM, director of the Center for Health Services Research and vice chair of the department of internal medicine at the University of Kentucky in Lexington, says he’s stunned by the sheer number of entrepreneurial readmissions management programs and systems on the market.

“Obviously, people see a need. But I’m not that sanguine about this new tech stuff,” says Dr. Williams, Project BOOST’s principal investigator.

There has to be some kind of integration with the hospital’s EHR, he says; otherwise, it just makes extra work.

“I wish our existing EHRs had the capacity to develop their own readmissions applications,” he says.

---

Larry Beresford is a freelance writer in Alameda, Calif.

HM15 Presenters: Roger Yu, MD, Cheng-Kai Kao, MD, Anuj Dalal, MD, and Amit Pahwa, MD

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

HM15 Presenters: Roger Yu, MD, Cheng-Kai Kao, MD, Anuj Dalal, MD, and Amit Pahwa, MD

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

HM15 Presenters: Roger Yu, MD, Cheng-Kai Kao, MD, Anuj Dalal, MD, and Amit Pahwa, MD

Summary: The panel of high-tech doctors helped a standing-room-only crowd navigate numerous apps to be used at point-of-care [PDF, 458 kb]. Groups worked through case studies utilizing applicable mobile apps. Examples and most useful apps, including occasional user reviews, follow:

Provider-to-Provider Communication, HIPAA secure

• Doximity.
• HIPAA-chat.
• Pros: HIPAA-secure, real-time communication.
• Cons: Both parties must be on app to securely communicate.

Provider-to-Patient Communication, Language Translators

• Google Translate: multiple platforms, free, 90 languages.
• MediBabble: iOS only, free, seven languages, dedicated medical application.

Diagnostic Apps for Providers

• Calculate by QxM.
• PreOpEval14: iOS only.
• PreopRisk Assessment: Android only.
• ASCVD Risk Estimator.
• MDCalc.com in addition to usual formulas, great abg-analyzer (online version only).
• AnticoagEvaluator.
• epocrates: calculators.

Click here for a PDF of useful apps and resource links  [PDF, 177 kb]

Resources for Evidence-Based Practice

• ACP Clinical Guidelines.
• ACP Smart Medicine.
• Read by QxMD.
• UpToDate.
• AHRQ ePPS: identifies clinical preventive services.
• epocrates.

Patient Engagement Apps

• Medication reminders: MediSafe, CareZone.
• Pharmaceutical costs: Walmart, Target Healthful, GoodRx.
• Proper inhaler usage: User Inhalers App.
• Smoking cessation: QuitSTART.

HM15 takeaways

• Apps are available to providers and patients to enhance quality, value, and compliance;
• Before “prescribing” any app to patients, vet the application yourself; and
• Use apps to supplement your clinical practice, but be wary of becoming over-reliant upon them, to the detriment of long-term memory. In order to utilize information in critical-thinking processes, it must be stored in long-term memory. TH

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

 

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

---

Karen Appold is a freelance medical writer in Pennsylvania.

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

 

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

---

Karen Appold is a freelance medical writer in Pennsylvania.

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

 

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

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Karen Appold is a freelance medical writer in Pennsylvania.

Patient-safety guru Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, talks about hospitalists’ role in improving the American healthcare system.

Patient-safety guru Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, talks about hospitalists’ role in improving the American healthcare system.

Patient-safety guru Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, talks about hospitalists’ role in improving the American healthcare system.