Is your emergency department a radiation hotbed?

By Joel A. Stettner, MD

As an emergency physician, I’ve certainly had to deal with patients who seem to equate more tests with better medicine. “What’s that you say, you bumped your head last week and you’ve heard that a CT scan is needed to make sure there's no serious injury?”

For patients like these – and you know the one’s I’m talking about – I have no problem drawing the line with a gentle but firm “no” accompanied by an explanation.  Granted, denying unnecessary tests that most patients in the United States are accustomed to requesting is not always the easiest road to take. But it’s the right road. And it’s one more emergency docs need to take.

According to a recent story reported by the Associated Press, the U.S. accounts for half of the world’s most advanced procedures that use radiation, and the average American’s radiation dose has grown six-fold over the last couple of decades. That also means that American patients receive the most radiation in the world.

To which I say let’s help get a grip on this problem.

I understand the reticence to say no, with fears of malpractice lawsuits driving a good portion of unnecessary tests. However, there’s a real danger since it is almost impossible to keep track of the number of CT scans and other exposures to radiation patients accumulate. A patient with, for example, renal colic symptoms could easily accumulate multiple scans over a short period of time, especially if multiple ED visits are required for evaluation and pain control. We now know that up to 2% of cancers are due to radiation from diagnostic tests, so these patients could well be at high risk for malignancy later in life. 

In my view, managing a patient’s testing expectations and warning them about the dangers of potential high levels of radiation due to non-mandatory tests should be emphasized. 

Efforts to do so must go beyond the ED and extend to private physician offices, health-related publications, and the popular press. Of course it would be helpful to reduce litigation fears, and the associated defensive testing, but healthcare tort reform remains an elusive goal, at least for now.

Please let me know how you deal with this problem in your practices.

What does Specialty Certification mean to PA’s?

By Natalie Schmitz, PA-C

In emergency medicine, any decision that has the potential to impact a large group of people, can elucidate many pros and cons.  Such is the case with specialty certification – which is a very contentious issue right now. 

On the one hand, it seems like a good idea.  After working in emergency medicine for some time, obtaining a certification to attest to one’s level of experience seems like a natural progression.  Furthermore, with the estimated emergency physician shortage, PAs will be called upon more than ever to fill the gap in the ER.  It seems logical that there should be some standardization of what it means to be an Emergency Medicine PA!

On the other hand, although not the intention, specialty certification may hinder the very flexibility that has made the PA profession so versatile and allowed PAs to fill a much needed niche in extending healthcare to a growing population.  After attending several SEMPA conferences it’s truly apparent that PAs are utilized very differently in various practice settings.  Some PAs practice only in fast-track settings, while in remote access emergency rooms, a PA may be the only on-site practioner.  This wide range of utilization makes standardization very challenging.

Also to be considered, are there unforeseen consequences of such specialty certification from outside organizations? For example, will certification or lack thereof affect reimbursements from insurance companies?  How will hospital credentialing committees deal with PAs who do or do not have certification in their particular specialty?  If specialty certification is offered, will your hospital or employer require certification and will it affect pay rates?

Regardless of opinion, it’s important to be involved in the decision making process.  For example, when NCCPA approached SEMPA and our ACEP liaisons for input, a focus group put together a proposal of requirements for such a certification.  During the recent AAPA House of Delegates (HOD) meeting, policy was almost unanimously approved to recommend that PAs not take specialty certification exams, but instead have a committee appointed to look at alternatives to specialty recognition. 

As the discussion continues to evolve, it’s necessary to voice your opinions. I urge you to contact your representatives from NCCPA, SEMPA, and/or AAPA and let your voice be heard! 

I look forward to your comments.

Note: The opinions of Ms.Schmitz are designed to encourage discussion and do not necessarily reflect the viewpoint of SEMPA.

Accountable Care Organizations: good for emergency medicine?

By Ellis Weeker, MD

Those of us in emergency medicine have been hearing a lot about Accountable Care Organizations (ACOs). The accountable care organization model has taken on far greater significance since being unveiled as one of Medicare's pilot programs in the Senate's health reform bill.

In an ACO, groups of providers share a financial incentive to control costs and improve quality by closely coordinating care. By being reimbursed a fixed fee for the entire care of such select medical issues as a heart attack or a car accident, providers have financial incentives to keep costs down and quality up. 

For example, ACOs would not receive additional payments if a person is readmitted for that same medical episode within 30 days. Theoretically, this encourages providers to eliminate medical errors. 

Some people say ACOs are nothing more than HMOs in disguise. But when you dig a little deeper, there are differences:

• The "accountability" rests with the providers. Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
• Physicians can contract directly with provider organizations without the reliance on a health plan intermediary.
• The ACOs allow for flexibility in the type of organization. Some regions may prefer independent practice associations (IPAs) while othersmay prefer a physician-hospital organization (PHO).

So what does this mean to an emergency physician or emergency department? In my view   there is risk and opportunity. Single specialty groups such as emergency physicians could find themselves contracting with ACOs instead of hospitals or insurance companies in the future. If they do, they must make sure they are at the negotiating table whenever possible.

If the local IPA moves in this direction, emergency physicians should seek to become part of the governance structure in order to have a voice. If not, we will have as little control as we currently have by contracting with the insurers. If we do, we might actually increase our influence!

Whether the ACO model is the panacea for runaway heath care costs remains uncertain. What is certain is that our current fragmented system incentivizes providers to offer neither cost-effective nor coordinated care. The status quo has got to go.

What are your thoughts on accountable care organizations? Please send me your comments.

The never ending road to reforming healthcare reform.

By Marty Ogle, MD

"Those who cannot remember the past are condemned to repeat it", George Santayana said. He wasn't talking about healthcare reform. But he could have been

As an emergency physician, I deal with our still-broken healthcare system every day. Which got me to thinking about the long and winding road that started 17 years ago surrounding "healthcare reform". The road has not only been long, it's been bumpy.

Let's venture back to 1993, when the "architect" to fix the broken American Health Care System was none other than the US Health Care Insurance industry!

Right out of the gate, President Clinton assigned Hillary to drive the overhaul of healthcare in the U.S.  Ms. Clinton plowed ahead, soliciting no input from those involved in delivering healthcare as they may biased. Instead, the ideas was to use policymakers (surely they are unbiased) and academic "experts" in health policy (certainly they know how to deliver better care to Americans). Then create a diagram that resembled UFO landing coordinates to explain it to the American People.

I remember thinking that I needn't worry because the plan would collapse under its own weight.

What I didn't see coming was the insurance companies coming up with "managed care" as the final wooden stake, just in case the Plan regained a pulse. "No need for sweeping reform", the Insurance Industry would claim. "We can control costs".       

Over the years, managed care established it's "footprint" across much of America - similar to how a tornado establishes a footprint when it takes out a trailer park.  

Then came 2009. The players changed, and now "ObamaCare" was here. Sort of. The bipartisan version of ObamaCare didn't work so well and the Dems and their colleagues across the aisle couldn't agree on anything. So the President took things into his own hands, developed ObamaCare and put on a bipartisan summit. Great news, except that the Dems and Republicans still couldn't agree to agree. In fact, the Democrats had trouble agreeing with each other.

But wait - let's try politics! Get the AMA's support by promising an SGR fix. Mollify the Hispanic Caucus by providing Immigration Reform (yeah, that worked).  And so it went.

Sadly, it was not to be. And ObamaCare limped to a halt. Except a gaffe by the Insurance Industry gave the plan an 11^th hour "elixir of life".

Public indignation caused by Anthem Blue Cross's announcement that they were raising premiums 39% for thousands of policyholders pushed ObamaCare across the finish line, with the assist of some questionable procedural footwork in Congress.

So there you have it; a rather truncated history of U.S. healthcare reform over the last 17 years. Don't you feel better off?  Or maybe we should start over. I hear Bill Clinton is looking for work!

I look forward to your comments.

Hospital and ER turn a $25 million loss into an $8 million gain.

In these challenging economic times for healthcare and emergency medicine, it's nice to report a story with a happy ending.  

One such story emanates from this week's Healthcare Financial Management Association's annual ANI conference in Las Vegas. As reported in healthcarefinancenews.com venerable Natividad Medical Center has announced that they've turned a $25 million loss into an $8 million gain in just four years.

Natividad, a 172-bed acute-care safety net medical center owned and operated by Monterey County, California has been a fixture in the community for more than 100 years. Over time, a series of poor management decisions had the hospital on the verge of closing in 2006.

Natividad CEO Harry Weis and his team took over the hospital in 2006, instituting team-building changes among staff, setting financial perimeters through data collection, renegotiating contracts with HMOs and receiving a $10 million private donation from the communities' doctors to launch the recovery. Since then, the hospital has not only recovered, but prospered.

Natividad's emergency department has focused on ways to save money instead of cutting more. Triage was improved so that emergency patients are now treated and sent home if they have low acuity illnesses, freeing up beds for those with more severe problems.

Thanks to the changes, patient wait times have gone from around four hours to roughly 30 minutes. Patient satisfaction spread by word of mouth and the ER has increased the volume of patients, with fewer leaving before being treated.

In addition, the emergency department's billing system and fee scale underwent an upgrade for the first time in 10 years, matching the fees to those of surrounding hospitals.

"We want to debunk the myth that public safety net hospitals can never make money," said Jeffrey Bass, MD, who was director of Natividad's emergency department during the turnaround. "We don't think we're a fluke. This is a model that can be reproduced over and over again."

Part of the overall recovery, according to Weis, has been due to changing the culture of the hospital from "what we're doing is good enough" to one focused on pride in performance. Nurses are made key members of the success team. Employees are held accountable for the first time in years. And poor performers were let go.

Any comments or personal experiences on the topic? Please share.

 

Talking to ourselves: does Peer Review in Medicine really work?

By John Ruffner

If you're a physician, physician assistant, or nurse practitioner, you probably have a definite opinion on peer review.  Personally, after 25 years of participating in peer reviews I'm convinced that there is definite practical /clinical value for these programs in medicine.  That said, the question is: how can we maximize the benefits of the effort?

It's my viewthat organizations that can learn from within exhibit significantly higher levels of effectiveness.  They are better at discovering error or opportunities for improvement - and translating that knowledge into action or changed behavior.

It seems obvious that organizational culture is key to successful efforts at improvement from within - where frank, specific and sometimes pointed discussions are encouraged

The literature is replete with examples of very sophisticated organizations where, notwithstanding a lot of very skilled individuals, the culture actually discourages accurate and open discussion of problems ("Skilled Incompetence",  Harvard Business Review).  NASA culture has been criticized on this point and the Shuttle accident was blamed on the organization's unwillingness to hear ‘bad news'.    

While most medical peer review operations start by looking for ways to improve best practices, a number of factors often erode the effectiveness over time.   These include:

• Medicine requires professional training and practice where complete information may not be available (Medicine is still an art)
• Professional behavior is often protective of its own
• Legal consequences are always a risk factor
• By definition, peer review is considered ‘Monday morning quarterbacking'
• Sociology of the Group or Group Think - what's ok to talk about and what's not
• Talking ourselves into the picture we want to see (related to the above item)
• The discussion focuses on how to shift blame self reinforcing thinking (sometimes appropriate)
• The discussion focuses on how to classify the case
• Focus on getting through the agenda

So, with these forces at work, what can be done to maximize the benefits (improve clinical care) of peer review? In my opinion, establishing a culture of openness and inquiry - one that encourages questions and scrutiny - is key. If a peer truly does not feel that the culture allows for honest comment, they will never speak up. 

That's why it's imperative for a practice or healthcare organization to establish a mechanism for clearly stating and presenting ‘lessons  learned' or the conclusion with differential explanations.  This can most often be accomplished by a summary of findings at the end of each review and a clear statement of the conclusions with everyone's attention turned to this activity.

What are your thoughts on peer review? Do you have a system in place where you practice?  Please share your thoughts.

 

Mr Ruffner has served in many roles both in acute care and physician organizations over the past 25 years.  He holds a MPH degree from UC Berkeley and has served on the faculties of several universities.

Hospital sees drop in emergency department patients after crack down on pain meds.

 

 

People coming into the emergency department hoping to score illegal pain medications are a widespread concern for emergency physicians.

But as recently reported on Starnews.com, one North Carolina hospital's crackdown on powerful painkillers for emergency department patients has led to something very interesting. A quieter ED.

People Dosher Memorial Hospital has seen "a bit of a decline in the emergency department in the number of patients that we’re seeing,” said hospital spokesperson Kirk Singer. “We believe it’s a pretty direct result of the passage and publicizing of our policy.”

The story goes on to state that the crackdown on painkillers in the ED was adopted in December of last year. Emergency department physicians would no longer use or prescribe Schedule II, III or IV narcotics for patients who come in with ongoing, chronic conditions.

The drugs in question include codeine, oxycondone and morphine among other narcotics. The new rule – while strict – is not Draconian. It's not meant for patients who come into the emergency department after a painful accident or aliment and legitimately require painkillers for their situation.

Instead, Singer said, it was directed to people who visit frequently with complaints of migraines, back and neck pain, dental pain, fibromyalgia or other chronic pain syndromes out of concern they could be faking to get the pain medicines.

In these cases, the emergency department must direct these people to their primary care physicians if they need a new prescription or are given a list of area clinics if they don’t have a primary doctor. They also might get info about resources for substance abuse counseling and treatment.

According to Singer, “There are a number of people out there who have been shopping for pain medication, and it’s a real problem when they start using controlled substances and prescription medications. In talking with the folks in law enforcement, we’re told by them, that it is a real problem not only in our community but statewide and across the country.”

Is Dosher hospital's new rule the secret to "emergency department overcrowding"? Not likely. But it is an interesting approach to a longstanding problem. 

As emergency physicians age, how to we prepare?

By Joel Stettner, MD 

As a now-seasoned emergency physician, I started my emergency medicine practice in 1974, moving directly from a rotating internship and internal medicine residency to a community hospital emergency department.

The transition was easy, since I had done ER moonlighting during my residency (back in the day, I guess), and I really enjoyed the practice. As you might imagine, I have accumulated a few years since then, and I continue to see patients - although with reduced clinical hours. Not surprisingly, I have noticed that many practicing ED and community physicians' colleagues are also aging. In fact, in some specialties, including emergency medicine, there seems to be a developing shortage of younger doctors who will be there to take over what promises to be a growing workload.

When I first started, emergency medicine seemed to be a young person's game. Especially given the stress and shift work requirements that came with the job. Over time, emergency physicians  found ways to continue practicing with the help of mid-levels and creative schedules. But as more and more physicians make the decision to retire, who will be there to step in and do the work?

Several developments are especially worrisome in this regard. Population growth in the United States continues its upward trend and health care reform legislation will add millions of newly insured patients who will be seeking care. A widely recognized lack of primary care physicians, coupled with a shortage of boarded-certified ED physicians - as well as retirement for many in these and other specialties over the next few years -  portend a growing demand for services in the face of a declining ability to deliver. And new organizations, including ACOs, Medical Homes, and Foundations, will need to meet their health care service needs.

We can hope that technology (telemedicine, EHRs, Internet applications, etc.) will help, and that mid-levels can take on greater responsibility. But I think we need to take a careful look at how we train young physicians, and the environment in which they are expected to practice. Then perhaps we can develop a more comprehensive approach to what will happen as our physician population continues to age in emergency medicine and other specialties.

I look forward to hearing your thoughts on the topic!

Is the iPad® about to change emergency medicine?

As noted recently in Emergency Physicians Monthly, the iPad is causing a growing number of emergency physicians to think about ways to use the device in the emergency room.

Hype aside, just as the iPhone® changed mobile phones and the iPod® revolutionized the music industry, it's likely that the iPad will change the way work is conducted in the emergency department.

How? Because of the pace, the interruptions, and the need for information, the tried and true pen and paper method of operation denies emergency physicians easy access to patient data and decision support. Some EDs are using electronic information systems, with doctors sometimes more focused on the computer screen than on the patient. Still other EDs use scribes.

However in the not-too-distant-future, the iPad could potentially change everything, allowing emergency physicians and staff to use iPads to tap on elements of the history of the patient - all very quickly at the bedside. These tablets would also enable physicians to go over images and lab results with patients, and review diagnoses and instructions.

It will all come down to the buzzword of 2010 "apps". At present there are no fully integrated and comprehensive ED information system apps on the iPad. For now, an emergency department could use existent apps for patient education, interfacing with  PACS, or discharge instruction templates.

But once ED-specific apps are made available - and they will - it's likely that emergency physicians and nurse practioners could have a tracking board to monitor patients' bed status or vitals, voice transcription software that can export transcriptions to charts, and many more. Some experts are predicting that a vendor will eventually release an app that does it all, seamlessly interfacing with the enterprise, offering charting, computerized order entry, bed tracking, results review, and admission and discharge pathways.

So even though the iPad is currently in its infancy, stay tuned. Before you know it, the technology will likely liberate physicians and have them chuckling about the "old days" of desktop ED information systems and paper charts.  

Any thoughts on the topic?  Please share!

Physician assistant or associate? What’s in a name?

By Cyndy Flores, PA-C

There has been significant discussion over the past week or so re: a potential name change for PAs. The point in question is a proposal to change the name from "Physician Assistant" to "Physician Associate".  Yes, we've heard this before, but once again there seems to be momentum to make a change.

Of course what may seem like a simple name change to some, can become a major bone of contention to others. Which is where this story gets more interesting.

In a recent article written by Dr. Marya Zilberberg, MD, MPH entitled, "Physician assistant name change rubs doctors the wrong way" she addresses the sometimes heated rhetoric surrounding the issue. A lot of the rhetoric comes from physicians who feel the word "Associate" implies a medical doctor.  Her takeaway is that there is an overreaction going on.

As Director of PA/NP Operations for a leading emergency physician partnership, I've been a clinically practicing emergency department PA for 20 years. In this time, I've come to understand and appreciate the interdependent relationship I share - and what all PAs share - with their supervising physicians.  It's what creates the cornerstone of what a health care team is really all about - a group of providers working together to ensure the best patient care possible. I've also been lucky enough to work the last 15 plus years for a group who truly feels that PA and NPs are partners in our organization and clinically practicing colleagues. 

And so it is that I don't find a great need to change my title to "associate", because I'm already treated like one.  Will being called an associate allow my patients to fully understand my role?  Probably not. But to the patient, what's most important, the title of the person caring for them - physician associate or physician assistant - or the fact they are receiving great and appropriate care? 

Changing the title would be no simple feat. It would mean changing any document (official or not), every law, every regulation, every by-law that has the title "physician assistant" on it. Changing the title would be a huge financial expense and with today's economic challenges I think there are better, more productive places to spend limited funds.  Also, there's so much going on in health care reform is a title change really a priority? 

Would the name change cause me to be more successful in my job?  Receive more money?  The title Physician Assistant is fine with me; it's up to me to give the job title definition and create the respect that I deserve. 

Any comments on the proposed name change? I'd love to hear them!