The American College of Physicians outlines when and how telemedicine can be used appropriately in primary care and what's needed to make it better.
Telemedicine is good, when it's an appropriate use of the technology, but there are still some hurdles to jump along the way to make it as good as it can be.
"Telemedicine is probably here to stay," says Wayne J. Riley, MD, MPH, president of the American College of Physicians, and clinical professor of medicine with the Vanderbilt University School of Medicine and adjunct professor of healthcare management with the Owen Graduate School of Management at Vanderbilt University. "We see a lot of potential good that can come from telemedicine, but it has to be done right."
Riley says the ACP heard from many of its 143,000 members who had questions about the role of telemedicine in their practice and their community, and who wanted to be thoughtful and appropriate in their use of it.
The position paper includes 13 main recommendations, which were developed after a review of studies, reports, surveys, and the legal landscape of telemedicine "through our very rigorous policy process," Riley says.
The recommendations can be broken down into two categories: Those pertaining to the immediate use of telemedicine and those calling for future action.
Telemedicine Today On the immediate-use front are recommendations that discuss when and how telemedicine should be used. For instance, ACP believes that telemedicine should "enhance patient–physician collaborations." Rather than using telemedicine exclusively, it's best used to either supplement an existing, in-person relationship or in consultation with another physician who does have an existing relationship with the patient.
The organization also advises that physicians exercise caution if they've never treated a patient in person before seeing them via telemedicine by either taking "appropriate steps to establish a relationship based on the standard of care required for an in-person visit," or consulting "with another physician who does have a relationship with the patient and oversees his or her care."
"We worry about the initial telemedicine encounter that is only established through telemedicine or a video link," Riley says. He acknowledges that some emergency situations require quick triage decisions via telemedicine, and suggests that follow-up care be done in person with the patient's regular doctor.
Another recommendation calls on physicians to "use their professional judgment about whether the use of telemedicine is appropriate for a patient." Riley says nothing can replace the exam room for a patient-physician encounter.
"It's not sufficient just to have telemedicine," he says. "You really have to get in to see your doctor."
He points to managing chronic conditions as a good example of the judicious use of telemedicine; instead of seeing a patient in-person once a month, perhaps some of those visits can be done via video chat.
In addition, not every condition is appropriate for telemedicine.
"You can't diagnose a brain tumor by video link," Riley says. "It's probably not a good idea."
Calls to Action Other recommendations include calls to action, such as the need for developing "evidence-based guidelines and clinical guidance" for telemedicine's appropriate use.
In addition, because "telemedicine is an appropriate medical encounter," the ACP believes it should be reimbursed as such.
"We do advocate for appropriate reimbursement for telemedicine service," Riley says. Although encounters may not occur in-person, "it is still using the cognitive skills" of physicians and is therefore should be compensated.
The guidelines call for "reimbursement for appropriately structured telemedicine communications, whether synchronous or asynchronous and whether solely text-based or supplemented with voice, video, or device feeds in public and private health plans, because this form of communication may be a clinically appropriate service similar to a face-to-face encounter."
Reimbursement for telemedicine today is "all over the map," Riley says, and varies by state. Because of this, telemedicine is "going to be very diverse in its penetration through the country." Similarly, "there's no one federal standard for telemedicine," he says, because the practice of medicine is governed by states and territories.
A streamlined process to obtaining several medical licenses that would facilitate the ability of physicians and other clinicians to provide telemedicine services across state lines while allowing states to retain individual licensing and regulatory authority
Allowing hospitals and critical access hospitals to give "privilege by proxy"
Lifting geographic site restrictions that limit reimbursement of telemedicine and telehealth services by Medicare to those that originate outside of metropolitan statistical areas or for patients who live in or receive service in areas where there is a shortage of health professionals
Riley says physicians and healthcare leaders who are interested in the future of telemedicine should pay attention to what's happening in their states, because that's where the "action really is."
"You have to be very attuned to what's going on in your statehouse," Riley says. "That's where it's appropriate for our members to participate in the rule setting."
HealthLeaders Media LIVE from Mercy: Telemedicine; Healthcare's Nerve Center, will be broadcast on Thursday, October 22, 2015, from 11:00 to 2:00 p.m. ET. Mercy Health System reveals underlying reasons for their successful implementation of telemedicine. How telemedicine has enabled them to improve outcomes, reduce costs, provide their clinicians better quality of life, and made them an increasingly attractive value proposition to payers.
Physicians feel frustrated and angry about what they describe as needless information that clutters patient notes in electronic medical records systems, research shows.
"If you want to get a physician angry and talking, get them to talk about their electronic health record," says Richelle Koopman, MD, associate professor of family and community medicine at the Missouri University School of Medicine.
It's no secret that discontent among doctors is widespread. A report released in 2013 by the American College of Emergency Physicians pointed to errors in patient care, attributed to electronic health record systems used in emergency departments, as "incredibly common." A year ago, the American Medical Association said physicians are "increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients" and called for a design overhaul of EHRs/EMRs.
Richelle Koopman, MD
Koopman is the lead author of a new studyin the Journal of theAmerican Board of Family Medicine showing that clinic notes in EHRs need a serious redesign if they're to be as useful as possible for physicians.
"We studied what information physicians need when they're about to see a patient and how they get that information that exists in the electronic health record," she says.
The researchers presented primary care physicians with fictitious patient notes for both an acute care visit (cough) and chronic care visit (type 2 diabetes, hypertension, hyperlipidemia, and depression) and watched them navigate through the EHRs/EMRs as though they were preparing for a patient visit. The physicians highlighted the parts of the note that they found important and unimportant, and researchers interviewed them about their choices.
The researchers found that the assessment and plan sections of the clinic notes were most important to physicians. These were the elements of the note that physicians reviewed first; they even jumped past other sections to get to this information.
On the other hand, the "review of systems" section, a billing element required by Medicare, was not only considered the least important section, but was almost completely ignored by the physicians.
"They thought that that was largely extraneous, and in fact, it angered many of them because it took up so much space," Koopman says. Indeed, she says the "main theme" of the interviews and research findings were the strong emotions and frustration conveyed by the physicians.
The review of systems in particular was "a lightning rod for that anger" because it obscured information physicians actually needed. "That's a great recipe for frustration," she says. "Something that people feel is required, but doesn't really help them."
Poor Design Koopman says part of the problem stems from the fact that EHRs/EMRs were originally designed to be familiar in look and feel to paper health records. Designs tried to mimic tabs for vital signs, medication lists, progress notes, test results, and other sections. As a result, users must click through different screens to access the sections that they need.
"That is a paper paradigm, and we have been slow in moving toward things like dashboards and Web capabilities," Koopman says. "Duplicating all of that information in the note doesn't really take into account the workflow that the physicians are now using."
She says other research has shown that dashboards are better for telling "the whole story in one screen."
In addition, EHRs/EMRs prompt users to document a lot of things in the note, which create pages and pages of information that physicians often consider unnecessary.
Too Much Info "There is all this documentation, and it tends to obscure the meat of the matter. So it's a problem of too much information," instead of quickly telling users what they need to know about the patient, Koopman says. She adds says that extraneous information in the EHR/EMR is not only troublesome to read, but also to generate.
"Putting all that together is a significant workload too," she says. "It's both about the organization and what needs to be there."
Having clear clinic notes and a clean, user-friendly EHR/EMR design is about more than simply making physicians' lives easier or alleviating physician complaints that using EHRs take up too much of their time. Too much EHR clutter and information overload makes physicians fear they may miss a piece of critical patient information.
"There are big concerns about what information is presented and how it should be presented. People feel like this is a very high-stakes safety issue, so it's very important to get it right," Koopman says. "If we can figure out the best way to make most salient points stand out clearly, that will be an important patient safety issue. It's not just about time at all."
Although EHR/EMR developers can view this study as a call to action, real change needs to "start with Medicare" because its requirements drive EHR design and documentation requirements," Koopman says.
"Medicare might need to revise the way it evaluates payment based on documentation," she says. "The more that we can make it easy [for physicians] to do the right thing because they're getting the right information, the better our EHRs/EMRs will be."
The percentage of healthcare clinicians who say they wouldn't recommend their electronic medical record system to a colleague has grown from 24% in 2010 to 51% in 2014.
Electronic health records systems are failing to live up to clinicians' expectations in terms of cost savings, efficiency, and productivity, and clinician satisfaction with EHRs/EMRs is on a southbound track.
According to several years' worth of survey results, physicians, nurse practitioners, and physician assistants are growing increasingly disenchanted with their EHR/EMR systems each year. The 2010 survey, for instance, shows that 39% of respondents were satisfied and 22% were very satisfied with their EHRs/EMRs, compared to 22% and 12%, respectively, in 2014.
The percentage of clinicians who say they wouldn't recommend their EHR product to a colleague has grown, from 24% in 2010 to 51% in 2014.
But digging into the survey results reveals nuances. Kellyn Pearson, manager, practice support, at the American College of Physicians, notes that the longer a clinician has been using an EHR/EMR, the more he or she is satisfied with it.
"Those people that adopted in 2012 had only been using their system for two years, so a large percentage of the respondents were in that category," she says. "The longer people have used their system the more apt they are to be satisfied with it."
Satisfaction Grows with Time
Although just 33% of respondents overall said they were satisfied or very satisfied with their systems, that number went up when it was analyzed by the number of years the system had been in use. Only 22% of people who had been using their system for less than a year said they were satisfied or very satisfied with it, compared to 50% who had been using it for five or more years.
"It takes a while to learn these systems," Pearson says. Plus, the Meaningful Use program keeps changing, making the learning curve even steeper.
"If people are part of the Meaningful Use program, what they're doing within their EHR/EMR is changing as well, because there's more requirements as time goes on," Pearson says. "I learn how to do this function, then there's a new one added, so I have to learn that one, and another one, and another."
But while some of the dissatisfaction can be explained by the novelty of the systems and the difficulty that comes with learning new technology, Pearson says the EHR/EMR "systems still need to be improved for their usability."
"I wouldn't say there are any numbers in here that show that anybody is overly thrilled with their system… It goes to show that these systems are in early development and still have a ways to go to meet all of the needs of their users," she says.
Indeed, a 50% satisfaction rate among users who've had their systems for five or more years is mediocre at best. Also, 54% of respondents found their EHR system increased their total operating costs.
"Even [among] with those who've used it a long time you're not seeing huge satisfaction with them, it's just that they're less dissatisfied," Pearson says.
She adds that EHR/EMR developers should work on easing clinicians' workloads and making documentation easier.
The survey showed that less than half (46%) of respondents said it was easy or very easy to document a progress note for each patient encounter. And that ease of use goes a long way toward satisfaction: 84% of those who were satisfied or very satisfied with their EHR said it was easy or very easy to document a progress note. Satisfaction with a system's billing function was also down overall, but billing function satisfaction is also linked to overall EHR/EMR satisfaction.
Justified Complaints this should send a message to healthcare leaders and executives that all the "complaining and grumbling about having to use an EHR/EMR," is likely somewhat justified, Pearson says. Executives should also know that "satisfaction with their systems doesn't occur after six months or a year," she adds.
Despite the learning curve, though, the survey shows that the usability of the systems themselves still leave a lot to be desired.
"The overarching thought is that there's still a ways to go in the usability and making these fit within the workflow," Pearson says.
The Medicare rule requiring at least a three-day hospital stay before patients become eligible for coverage of skilled nursing care afterward "may be inappropriately lengthening" hospital stays, a researcher says.
Cost savings and less time in the hospital are the result when Medicare Advantage plans waive the decades-old rule requiring at least a three-day hospital stay before patients become eligible for coverage of skilled nursing care afterward, according to a new study by researchers at Brown University and published in Health Affairs.
The three-day rule for skilled nursing care eligibility was implemented back in the 1960s, when the average hospital stay was two-weeks long.
Amal Trivedi, MD, MPH
"Times have changed," says Amal Trivedi, MD, MPH, associate professor at the Brown University School of Public Health, senior author of the study. Now the average length of stay in the hospital is about five days. So it would be reasonable to expect that it would also take less time for a care team to determine whether a patient should be discharged to a skilled nursing care facility.
"Every day in the hospital comes with some risk," Trivedi says. Plus, "A day in the hospital is quite expensive."
"If we could get patients out quicker it would be good for the patient, but also good for the Medicare program," he says.
Medicare Advantage plans have more flexibility than traditional Medicare, and most of them have waived the three-day rule. Plans that waived the rule within the study period set up a natural experiment.
Comparing 14 plans that waived the rule during the study period with 14 that had the rule in place, allowed researchers to track changes over time.
They found that between 2006 and 2010 the average time in the hospital per year increased by half a day among 140,739 people in the plans that never waived the rule, but decreased by 0.2 days among 116,676 people in the otherwise similar plans after they waived the rule.
"The decline in length of stay was 0.7 days (or 10%) among hospitalized patients admitted to a skilled nursing facility," Trivedi says. "Given the estimated costs of a hospital admission among a Medicare beneficiary, we estimate a savings of $1,500 for every admission concluding with a discharge to a SNF [skilled nursing facility]."
In addition to the estimated cost savings, less time in the hospital also means a smaller chance of patients developing hospital-acquired complications, such as blood clots or infections.
Waiving the rule not only resulted in a reduction in hospital days, but it also didn't have "any evidence of adverse effects," Trivedi says. For instance, it didn't increase the probability of skilled nursing admissions, the number of skilled nursing admissions, or even the length-of-stay in a skilled nursing facility, the study said.
Neither did the researchers find increases in the average number of hospital admissions in the study population, which could have been a consequence if patients were discharged too early.
Wider implications of the study are harder to gauge.
"To what extent do these results generalize to the traditional Medicare program?" Trivedi asks. That's a question for further study, the researchers conclude. Currently, the traditional Medicare program isn't free to waive the three-day rule the way Medicare Advantage plans are. They also suggest exploring the effects of eliminating the three-day hospital stay requirement on acute and post-acute care in ACOs.
According to the study, the cost savings estimated in this research "are unlikely to be generalizable to the traditional Medicare program" because of payment differences. The study does note, however, that hospitals (rather than the Medicare program) could realize cost savings for decreased length of stay.
One thing is clear: "The policy may be inappropriately lengthening" hospital stays, Trivedi says.
Wide variations in radiation therapy costs illustrate that factors associated with individual patients or their tumors have little to do with the actual cost of treatment, researchers find.
Factors associated with individual patients or their particular tumors hold little sway in determining the cost variations in radiation therapy for cancer patients according to a recent studyof Medicare patients.
In fact, those factors accounted for less than 3% of the variation in the cost. Instead, factors having nothing to do with the patients themselves—the year of diagnosis, treatment location, and individual providers—accounted for a large chunk of the variation.
Murphy says he and his colleagues expected the correlation to be low but, "we didn't think it was actually going to be that low," he says. "That was probably the most surprising finding."
James Murphy, MD
Getting a handle on what's driving the variation in costs was the impetus for the study.
"Radiation oncology is a small specialty in the scope of healthcare but the cost associated with treatment is relatively high compared with other services patients receive," Murphy says.
In fact, the total cost of radiation therapy for the 55,288 patients in the study was estimated to be more than $831 million. The researchers identified those patients in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) databasewho were diagnosed with breast, lung, or prostate cancer between 2004 and 2009. These cancers were chosen because they're the most common ones that are treated with radiation therapy.
The researchers found that the median cost of a course of radiation therapy—estimated from Medicare reimbursements—was $8,600 ($7,300 to $10,300) for breast cancer, $9,000 ($7,500 to $11,100) for lung cancer, and $18,000 ($11,300 to $25,500) for prostate cancer.
The cost variations that were based on factors "including practice type, geography, and individual radiation therapy provider, accounted for a substantial proportion of the variation in cost, ranging from 44% with breast, 43% with lung, and 61% with prostate cancer," the study reports. For instance, radiation therapy was least expensive in Hawaii and most expensive in Washington State.
The study also found that "the cost of radiation therapy increased from 2004 through 2007, decreased uniformly across all disease sites between 2007 and 2008, and resumed an upward trend again in 2009."
Murphy says that this study and others like it potentially shows inefficiency in the healthcare system, and provide some impetus to move away from the current fee-for-service-based reimbursement schema. He adds that evidence for that conclusion is coming from a lot of different angles.
But "what a better option is, I don't really know," he says, noting that ideally researchers should test out different policies to see what's best.
He adds that parsing out cost and quality is difficult to do in cancer care and radiation oncology.
"Cancer just by its nature is a little more fragmented," he says. For instance, patients might get radiation and chemotherapy at different facilities. Also, defining outcomes in cancer care can be complicated, and once they are defined, those outcomes are sometimes measured over several years. In addition, adverse effects, such as radiation toxicity from treatment, can take years to manifest.
"Trying to reimburse for patients today for outcomes happening years down the road is complicated," Murphy says.
He says that there's been quite a lot of interest in this study; "Anytime people start asking about reimbursement and cost it's always of interest."
And there are many stakeholders.
Murphy notes that radiation oncology is a high-revenue generating specialty, and because there could be major changes in the way it's reimbursed in the future, hospital and other healthcare leaders should pay special attention.
Others are also closely examining the cost of cancer care. Earlier this summer, the American Society of Clinical Oncology (ASCO) published an initial version of a conceptual framework for assessing the value of new cancer treatment options based on clinical benefit, side effects, and cost. ASCO's framework is open for public comment through August 21.
"My personal opinion is that it's really promising that ASCO is taking this on," Murphy says.
Finally, there are the patients themselves to consider, who Murphy suspects are "not at all" aware of the many differing factors that could lead to variations in the cost of their radiation therapy.
"I don't think patients are even aware of this at all," he says. "The patients are at a distinct disadvantage when it comes to understanding the cost of healthcare."
A new study raises questions about whether the rhetoric of cost-effective care is being applied to real-world clinical training.
Resident physicians are twice as likely to order an expensive, brand-name statin when they're supervised by attending physicians who prefer those medications in their own practice.
"I wasn't at all surprised by the study," says Deborah Vozzella Hall, MD, national president of the American Medical Student Association(AMSA). "We are obviously influenced by what our teachers think. That's part of the nature of a teacher and student relationship."
But the study does raise questions about whether the rhetoric of cost-effective care is being applied to real-world clinical training.
"I don't think it is surprising that the most junior residents were prescribing like their supervising physicians. As an educator, I would expect residents to adopt their attendings' practice style," says Kira Ryskina, MD, a general internal medicine fellow at Penn and the study's lead author, responding to questions by email. "However, it was surprising to find that many attendings' prescribing was not aligned with cost-effective practices suggested by the "Top 5" list."
Generic vs. Brand Name "We wanted to determine whether residents… base their prescribing preferences between generic and brand name drugs based on the preferences of their supervising physicians," she said.
The researchers' sample included 342 residents and 58 attendings who wrote 10,151 initial statin prescriptions; among those, 3,942 were written by residents. They found that the probability of a first-year resident prescribing a brand-name statin was 22.6% when they were supervised by attending physicians who prescribed less than 20% brand-name statins.
The probability rose to 41.6% when the first-year resident was supervised by an attending who prescribed at least 80% brand-name statins.
The same effect wasn't seen for second- or third-year residents, though.
"We found that the most junior residents were heavily influenced by the prescribing preferences of their supervising attendings," Ryskina said. "However, we were surprised to find no relationship for more senior residents."
In fact, "A higher post-graduate year level was associated with brand-name prescribing," the study said.
"There are several possible explanations for this, such as attendings are not supervising senior residents closely enough in the area of cost-effective care, senior residents are not following attendings' recommendations, or that residents' styles are set early on in training," Ryskina said.
Hall, of AMSA, says that although cost-effective practices, including an emphasis on critical thinking and evidence-based medicine, is taught in the classroom, "how much that translates into what is emphasized in our clinical training is highly variable."
"I think, inherently, we want the approval of our teachers and we want to do well, and I think that can play a bigger role, particularly as an intern," she says. "You're still very closely supervised."
Moreover, it's the role of the attending physician to challenge residents' decision making and clinical choices. But if residents are getting challenged too often, and too harshly, perhaps they will simply bend to their supervisor's will and preference.
For example, a resident's thinking might go like this: "I will just prescribe what Dr. Jones prescribes because in the end, I have to answer to Dr. Jones," Hall says.
She also points out that physicians can be heavily influenced by the pharmaceutical industry. Certainly this influence can bleed into student training, and even starts in medical school: medical school and teaching hospital scorecards to grade schools' policies and relationships with the industry (although it should be noted that the Harvard study found no correlation between the strength of a school's policy regarding industry interactions and whether students accepted gifts).
For instance,Perelman School of Medicine gets a "B" score (as of 2014), with "model policies" on preventing "faculty from being paid by industry to do promotional speaking, or to be on industry-funded speakers' bureaus" and not allowing industry-funded gifts of any nature or value, but having no policy about the access of medical device representatives.
"We think that medical education should focus on teaching people how to make evidence-based decisions," Hall says. "We should have strong conflict of interest policies in our programs, so we can make clinical decisions without undue external influence."
Certainly the new Penn study shows that there's still a wide gap between theory and practice, and between the classroom and the real-world, when it comes to providing low-cost care and following widely established recommendations.
"We hope this information will inform best practices to cultivate cost-effective care by physicians in training, an area of increasing emphasis in graduate medical education," Ryskina says.
Under new federal law, Medicare patients who have been in the hospital for more than 24 hours will be required to be notified of their status within 36 hours of when they start receiving medical services as an outpatient.
UPDATE: CMS on Wednesday, August 12, announced that it would extend the enforcement delay of the two-midnight rule through the end of the year. It had been set to expire September 30.
President Obama last week signed the NOTICE Act, which requires hospitals to inform Medicare patients who are in the hospital under outpatient observation status that they haven't actually been "admitted" to the hospital and what that means in terms of cost-sharing requirements and subsequent coverage eligibility.
The new law aims to eliminate the confusion and surprise of out-of-pocket costs for Medicare beneficiaries who might not realize that simply spending the night in the hospital doesn't make one an inpatient—and may leave one vulnerable to unexpected charges.
Medicare patients who have been in the hospital for more than 24 hours are required to be notified of their status within 36 hours of when they start receiving services as an outpatient. Hospitals are required to provide patients with verbal and written notification of their status and will have one year to comply with the law from the date it is enacted.
Under the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act the notification from the hospital must:
Explain the individual's status as an outpatient and not as an inpatient and the reasons why;
Explain the implications of that status on services furnished (including those furnished as an inpatient), in particular the implications for cost-sharing requirements and subsequent coverage eligibility for services furnished by a skilled nursing facility;
Include appropriate additional information;
Be written and formatted using plain language and made available in appropriate languages; and
Be signed by the individual or a person acting on the individual's behalf (representative) to acknowledge receipt of the notification, or if the individual or representative refuses to sign, the written notification is signed by the hospital staff who presented it.
Although the federal law won't go into effect until next summer, a handful of states have already written laws of their own requiring hospitals to notify patients of their outpatient status. Among those states is Vermont, which is currently developing a standardized form that hospitals will be required to use beginning in December.
Hospitals Take the Lead
Even before that, some hospitals have started to notify patients on their own. The University of Vermont Medical Center is one of the hospitals already notifying patients of their status.
"People say, 'I'm in a bed, doesn't it mean I'm an inpatient?" says Tara Pacy, RN, Director of Clinical Support Services at the University of Vermont Medical Center. It's hard for patients to know their status without having an understanding of the two-midnight rule, and they certainly don't always know that their copays and what services they qualify for after leaving the hospital are different depending on whether they're an inpatient or an outpatient.
Tara Pacy, RN
"We did get some patients concerned saying, 'Hey, I didn't know this, and now I owe this amount of money,'" Pacy says.
The Vermont law says that patients must be notified of their status in writing within 24 hours (the federal law requires 36 hours). According to Pacy, the University of Vermont Medical Center gives patients a hand-delivered notice from a case manager that begins like this:
You are in the hospital under observation. This means your doctor needs to watch you or do more tests to understand your illness. However, you do not meet Medicare's rules for inpatient admission. Even though you are in the hospital and you may stay overnight, Medicare considers you an outpatient. This affects what Medicare will pay for while you are in the hospital and after you leave the hospital. Your share of hospital bills may be larger than if you were an inpatient. If you go to a skilled nursing facility (nursing home) after you leave the hospital, you might have to pay the full cost of your stay.
The notice then goes on to offer explanations of what that means for people's coverage, such as what's covered and not covered under Medicare Part A and Part B, and phone numbers for departments within the hospital, as well as for services and resources outside the hospital, where patients can get more information.
Pacy says the notice letter has been modified over the past few months. For instance, previous versions of the notice tried to list and explain all the different statuses that a patient could be under, but that just complicated matters further.
Now, "we focus just on the observation status, which seems to be the one that confuses the system the most," Pacy says. And although it's rare, she says people have chosen not to go into a bed when they learn that they might be stuck with a hospital bill.
And although her office is working to develop a statewide, standardized form for all hospitals in Vermont to use, "what we'd really like to see Congress do is change those policies...it's really almost not even a clinical judgement," she says.
Both Pacy and Olson agree that patients need to know about their status. They also say that compliance with the rule isn't particularly difficult. But there are a few things to think about, such as making sure the language is clear and deciding who will provide the notice to the patients. Such specifics will be different within every hospital.
One best practice that Olson recommends is "really thinking through who is going to provide the notice to the patient." For instance, some hospitals have been working with discharge planners, others with case managers. In other hospitals, the ED staff might be the most appropriate people to provide the notice.
In addition, "thinking through all of the players" is seen as important because there has to be coordination with billing, too. Then there are considerations depending on the hospital's location and whether outside services are available. For instance, the Vermont form includes different outside resources to contact not only for Vermont residents, but also for New York, Massachusetts, and New Hampshire residents.
Olson says the state forms are still being adjusted, and time will be spent reviewing and comparing Vermont's law to the federal law and weighing different options, such as eventually amending or repealing the state law. She emphasizes that the policies themselves are a greater problem than the hospitals' notification requirements. "We really wish we could get some headway on the underlying policies," she says. "We don't really think it's great for patients."
An institution-specific surgical risk score can help avert the need for mechanical ventilation in high-risk patients, researcher says.
As a fourth-year general surgery resident, Adam P. Johnson, MD, quality and patient safety fellow in the department of surgery at Thomas Jefferson University Hospital in Philadelphia, says he has spent a good amount of time with patients in the ICU. And although it's rare—data shows that just 1% to 3% of patients who have non-emergency surgical procedures require ventilation afterward—he's seen some of those patients go into respiratory failure.
"When it does happen it's pretty sad," Johnson says. "And looking back over patients cases… I wish we could've done something before surgery to optimize them better to make sure this didn't happen."
That's why he and his colleagues decided to develop a scoring system to help systematically identify the surgical patients who are most at risk for pulmonary complications.
The researchers analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data of nearly 7,500 patients who had elective general or vascular operations at Thomas Jefferson University Hospital between 2006 and 2013.
They created a scoring system that assigned points for different factors, such as being a current smoker (1 point), older than 60 (2 points), and having undergone esophagus procedures (3 points). Other risk factors were severe chronic obstructive pulmonary disease; signs of active infection or inflammatory response; and low albumin counts.
"We were able to assign a point value to see how much each one contributed," Johnson says. Total risk scores ranged from 0 to 7.
He and his team found that the median risk score for patients who did not need the ventilator after operations was 2, whereas the score for patients who did need the ventilator was 3. Those with a score above 3 comprised the 20% of patients who experienced 70% of the adverse events observed.
"It's that high-risk group that's carrying most of the burden," he says.
Johnson acknowledges that his work isn't "groundbreaking" or unique.
"There are a lot of scoring systems out there," he says. But, he says a lot of existing risk scores are complicated and tough to use in clinical practice. And if a surgical case is urgent, "it doesn't really give you much time before surgery."
That's why he wanted to look at patients who were getting elective surgery.
"We would have plenty of time to help get them stronger and prevent these complications," he says. As hospitals perform elective surgeries on older and sicker patients, it's even more important to identify them and get them through their surgery safely.
Cost Factor
There's a cost factor, to consider, too: Other research shows that mechanical ventilation can cost $1,522 per day per patient in the ICU.
Johnson just presented the findings late last month at the 2015 American College of Surgeons National Surgical Quality Improvement Program Conference in Chicago, and is preparing a manuscript to submit for publication.
The next phase of his work will focus on developing strategies for incorporating the scoring tool into clinical practice, identifying high-risk patients early so they can have a standard set of interventions.
For instance, there might be aggressive smoking cessation programs, testing for high levels of nicotine in the urine before operating, or encouraging that some patients be operated on while awake and without intubation.
Focusing on the high-risk patients will get the biggest bang for the buck. "We may only have the resources to get some of the patients involved," Johnson says. "Everything we do in healthcare takes resources, so it's best to focus on those patients who would truly benefit from these interventions."
Although there are many scoring systems that exist, Johnson says this one is unusual because it is specific to this institution. Other hospitals will have a different mix of patients, and the variability of risk factors among the patient population at Thomas Jefferson University Hospital might be different from other organizations.
That's why Johnson believes it's valuable for clinicians at other institutions to develop risk scores specific to their institutions, too, to help them understand their own numbers. He says using databases to track outcomes can help hone in on areas where improvements can be made. He also suggests identifying other institutions nearby that are doing well in certain areas and working with them to share best practices.
Knowing institution-specific data can also help clinicians have more meaningful conversations with patients. When clinicians sit down with a patient, they don't just quote national rates for complications; instead they can say, "There is a likelihood that you, with your risk factors, will have this complication at this institution."
The practice of working while sick is common among physicians and advanced practice clinicians, even though it puts patient safety at risk.
Ask any healthcare manager whether they want their employees to come to work sick, and they'll certainly say they do not. But when a physician who's scheduled to see 20 patients that day calls in sick, or when a nurse approaches his manager to say he's too ill to work and needs to leave early, things can get complicated.
"You don't want anybody coming in sick, but if you don't have that coverage there, what are you going to do?" says Mallory Hatmaker, MSN, CNP, an adult/gerontology certified nurse practitioner with Cleveland Clinic's Employee Wellness and Internal Medicine departments.
Mallory Hatmaker, MSN, CNP
What sick clinicians often do is trudge through illness and work anyhow, says a new study published in JAMA Pediatrics.
"You can't tell the person that needs open heart surgery" that you're sick and you'll get to them tomorrow, Hatmaker says.
Researchers at the Children's Hospital of Philadelphiaconducted an anonymous survey of 280 attending physicians and 256 advanced practice clinicians. It found that although 95.3% of respondents believed that working while sick put patients at risk, 83.1% admitted to working while sick at least once in the past year.
A smaller number of respondents (9.3%) reported they had worked while sick at least five times. "Sick" symptoms included diarrhea (30% worked with these symptoms), fever (16%), and the acute onset of significant respiratory symptoms (55.6%).
Physicians were more likely than advanced practice clinicians to work with these symptoms.
Survey respondents said they worked sick because they
Didn't want to let colleagues down (98.7%)
Had staffing concerns (94.9%)
Did not want to let patients down (92.5%)
Feared of being ostracized by colleagues (64%)
Had concerns about the continuity of patient care (63.8%)
Such responses reveal the complex social, cultural, and even logistical issues that cause physicians and clinicians to come to work when they're sick, the study authors say. There's a "strong cultural norm to come to work unless remarkably ill," the study says. Written responses also showed confusion about what actually constitutes "too sick to work."
Hatmaker says she sees many of these issues come up in her work with Cleveland Clinic, where she heads up a system-wide nursing wellness initiative and also works for the internal medicine department's employee walk-in clinic at Cleveland Clinic's main campus.
Cleveland Clinic is trying to care for its staff through the employee walk-in clinic, where any any employee can come in for care without paying a co-pay. It's convenient for a doctor to get reassurance that he or she doesn't have strep throat if someone in their household has it, for instance, or for a nurse to get treatment for a poison ivy or a urinary tract infection without having to miss work, Hatmaker says.
But on the flip side, Hatmaker says she's treated nurses and physicians who have had a 102 fever and can barely sit up and talk to her, but who insist on going back to work.
A Patient Safety Issue "When I tell them, 'You're not going back to the floor,'" they can't believe it, insisting that they will try to stick it out and muscle through until the end of their shift, or saying they'll work just a few hours longer, she says.
"You get hard-headed employees. I'm one of them myself," she says.
But coming to work sick is not only bad for the clinicians themselves; it's also a patient safety issue. No one wants to be the person who spreads their germs to already-sick and possibly immunocompromised patients, not to mention to other staff members.
Managers need to use their discretion and tell employees, "you are sick, you can't be here" if necessary, Hatmaker says. "It's safety."
Although there doesn't seem to be a ready or easy answer to the problem allowing staff to sick versus being short-staffed, "prevention is key," Hatmaker says. "You have to listen to your body."
She says clinicians and physicians need to make sure that they get enough sleep, take their vacation days, manage their stress, and eat well, because all of those things can help prevent sickness in the first place. She adds that Cleveland Clinic tries to help its employees in this way with wellness initiatives and offerings, such as yoga, stress management tools, a sleep program, and more.
Still, it's hard for physicians, nurses, and other caregivers to admit that they're the ones who need to stay home and lay on the couch for a day or two. It's hard not to let guilt over letting patients and colleagues down get the best of you.
"It's the culture and it's the nature of the job unfortunately," Hatmaker says. "It's dedication to profession. It's workaholics…We're, I guess, a different breed. We're not the ones who are supposed to be sick."
Better advance-care planning strategies are needed, including recognition by healthcare leaders of the importance and value of palliative care as a field, says a Johns Hopkins researcher.
With more and more attention being paid to end-of-life care and advanced care directives, aggressive treatments on dying patients are not correspondingly decreasing as expected.
"Our findings did not quite reflect that," says Amol Narang, MD, a resident in the department of radiation oncology and molecular radiation sciences at The Johns Hopkins Hospital, first author of new research published inJAMA Oncology.
The researchers analyzed survey data from nearly 2,000 next-of-kin surrogates of Health and Retirement Study participants with cancer who died between 2000 and 2012. Over the 12-year study period, there was a 40% increase in the number of patients with cancer who participated in designating durable power of attorney privileges to a loved one. That increase, however, wasn't associated with the patients receiving less aggressive medical treatment during the last few weeks of their lives.
Amol Narang, MD
"Several measures of treatment intensity at end of life continue to be very high, just as high as they were 10–15 years ago," Narang says.
Aggressive medical treatment for end-of-life included such factors as whether patients who were terminally ill with cancer died in the hospital, whether they visited the emergency department during the last few weeks of life, were admitted to the ICU shortly before death, and failed to be referred to hospice until right before death.
"We know that end of life care in cancer patients can be aggressive," he says.
"People want to always have hope," Narang says. And "these conversations can be uncomfortable."
In the Hopkins study, not only did researchers find that aggressive care continued despite having a durable power of attorney, but many survey respondents said they never discussed end-of-life preferences with their loved ones, physicians, or anyone else. They did not necessarily want such aggressive care but no one had talked about it.
"We were especially surprised by the fact that 40% of survey respondents... were indicating that the patient had never discussed their preferences for the care they wanted to receive with anyone," Narang says. "I think that that speaks toward the fact that assigning a power of attorney without communicating preferences… may not be an effective form of advance-care planning."
"I think it just clearly points to the fact that we need to do more to support better palliative care at end-of-life in cancer patients," he adds.
What could make for better planning and palliative care are physicians having these difficult conversations with patients and family members. Narang says he's hopeful that the proposed CMS payments for end-of-life conversations will help advanced planning become a "routine and integral aspect of end-of-life care" and of care for patients with a terminal outcome.
"I think the CMS proposal is an option; finance supporting these conversations can help increase their frequency," he says.
Other strategies to increase end-of-life planning and reduce the kind of aggressive care that many terminal patients likely don't want include expanding training in palliative care and increasing the number of outpatient palliative clinics.
"I think those two kind of go hand in hand," Narang says.
Making these conversations routine will also help ensure that they happen in a controlled setting where parties can discuss things openly, honestly, and calmly, "rather than in a more urgent setting when decisions have to be made quickly."
Hospital executives have a role to play, too, Narang says, by "recognizing the importance and the value of palliative care as a field," as well as hiring palliative care specialists; training providers so they feel comfortable having these discussions; and providing a physical clinic space where these kinds of conversations can happen.
"I think that there are a lot of influences," Narang says. "I think better understanding of that is worthy of future investigations."