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6 Best Tips to Boost Your Documentation Process: Tip 3

  
  
  

documentation Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach. In this 6-part series, each Thursday, I’ll be sharing my most recent documentation tips.

by: Timothy N. BrunDage, M.D., CCDs

3. CoPD

COPD is the ninth most-denied admission diagnosis by the RAC. COPD is a chronic condition and should not be admitted to the hospital unless one of these issues is present:

  • Acute Exacerbation
    • Document acute exacerbation of COPD if admission is medically necessary and IV steroids and frequent nebulization treatments are required.
  • Acute Respiratory Failure – frequently the actual reason for the admission
    • Document with the clinical criteria are present
      • Requires two of the following three
        • Respiratory Distress – document this in the physical exam
        • PaO2 is less than 60 mmHG (pulse ox is less than 88 percent) or higher oxygen requirements for COPD patients on oxygen
        • PaCO2 is greater than 50 mmHg with a pH less than 7.5 (means acute)
  • Chronic Respiratory Failure is commonly a missed diagnosis associated with COPD
    • Home oxygen is greater than 16 hours a day (not just nighttime oxygen)
    • PaCO2 is greater than 50 when pH isn’t greater than 7.35 (means chronic)

Remember to document “Acute” on Chronic when appropriate.

brundageTimothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine 

 

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3 Benefits of Improving the Integration of Hospital & Emergency Medicine

  
  
  

emergency departmentThe Emergency Department is the front door for most hospitals. Consequently, the efficiency of that department to evaluate, stabilize and release or admit patients is a critical success factor for many organizations. But frequently, the inpatient admission process presents a bottleneck which causes the ED to fill up. One major cause of slow admissions it the lack of availability of a bed. Inpatients scheduled for morning discharge may linger on their unit awaiting discharge orders, final tests, physician rounds, etc. Integrating the management of the inpatient beds and the ED aligns processes to improve patient flow, achieve operational efficiency, and 

 

1. Improve capacity in the ED

2. Reduce ED boarding time

3. Improve patient satisfaction

For more on this topic, check out our white paper, Integration Changes Everything (no download required). 

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Innovation in Emergency Medicine: Harvesting the Ideas, Growing the Passion, and Getting it Done

  
  
  

innovationThis post is part of EmCare’s 4-part Innovation series where we highlight what innovation means to members of EmCare’s leadership. Follow this series each Tuesday to discover our commitment to innovation in health care.

 

By Kirk Jensen, M.D.

When people hear the term “innovation,” they often think of something brand new, something previously unheard, or the novel experience that comes from an “aha!” moment or insight. This can be an important component of an innovation process. However, innovation should also involve a commitment to basics - a reimagining of proven principles or a rededication to a proven system.

Innovation can and should focus on implementation and execution. When you look closely at innovation at the national or individual practice level, it’s not enough to have an innovative idea – it has to have a strong execution plan. It has to be widely and readily available. It has to be commercially viable.

For example, the demand capacity and predictive modeling program is familiar to a number ofPatient Flow people. Innovation comes into play and centers on the following: what is the best approach or program and how do you deploy it? How do you successfully use it to optimize the practice?

What are the key constraints, and how can we innovate our way around or through these constraints?

Initially, the innovation work proceeds along two significant streams or tracks. One of them is recognizing the current programs that are truly innovative and useful; and the other is how to diffuse, rapidly and successfully, the innovation. Another significant stream or track is: how can we harvest the “cool ideas” that are already being developed at the local or regional level? How can we recognize those ideas, harvest them, build out the appropriate toolkit, and deploy them region-wide or companywide?

I think there is a tremendous opportunity to look at the demand capacity modeling of patient flow, analyze the incoming streams of patient flow by severity, by hour of the day, and by day of the week. From there we can work on appropriately mapping our resources to these incoming patient flows. It gives us a wonderful opportunity to design and model the “ideal” clinical team and its makeup for an individual practice site the optimal combination of physician coverage, mid-level coverage, nursing, and scribe coverage. We can look at building out demand capacity modeling tools for anesthesia, surgery and other clinical service lines.

EmCare, from the top down, is really committed to this – getting the big ideas organized, implemented and shared nationwide. This is not a flavor of the month program. We think that fostering a culture of innovation and a process for innovation will allow us to deliver the kind of care we would all like to deliver, and provide us with a compelling and competitive advantage both in the marketplace and in recruiting.

I think it is often difficult on an individual level to figure out how to get one’s ideas to a location or to a level where they can be appreciated ---and where they can be deployed.

The EmCare Innovation strategy and approach provides individuals and groups a chance to do just that. In addition, it benefits not just EmCare, but our follow clinicians, our hospital partners and, best of all, the millions of patients we treat each year.

jensenKirk B. Jensen, M.D., MBA, FACEP, is Chief Medical Officer for BestPractices, Inc., an affiliate of EmCare. He is a leader in practice management, patient flow and clinical care. Author of numerous articles and three books, Leadership for Smooth Patient Flow (2007 ACHE Hamilton Award winner), Hardwiring Flow, and The Hospital Executive’s Guide to Emergency Department Management, coach and mentor for E.D.’s across the country, and acclaimed speaker, Dr. Jensen has twice been honored as the American College of Emergency Physicians (ACEP) Speaker of the Year. Dr. Jensen served on the expert panel and site examination team of Urgent Matters, a Robert Wood Johnson Foundation initiative focusing on elimination of E.D. crowding and preservation of the healthcare safety net. Faculty member of the ACEP management academy and The Studer Group, chair and faculty member for the Institute for Healthcare Improvement (IHI), writer and presenter for HealthLeaders Media, Dr. Jensen shares expertise on patient safety, patient flow, operational strategies, error reduction, and change management. Dr. Jensen holds a Bachelor’s Degree in biology from the University of Illinois (Champaign) and a Medical Degree from the University of Illinois (Chicago). He completed a residency in Emergency Medicine at the University of Chicago and an MBA at the University of Tennessee. Attend Dr. Jensen's presentation, "Winning Physician Buy-In" at the 2014 Patient Flow Summit. Details here: http://ow.ly/vw8rk.  To read Dr. Jensen's latest whitepaper, click here: http://ow.ly/vw8EH

 

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Benefits/Risks for Fibrinolytic Therapy in Intermediate-Risk PE

  
  
  
Cuts mortality, hemodynamic decompensation; ups risk of intracranial bleeding, stroke

FRIDAY, April 11, 2014 (HealthDay News) -- A single intravenous bolus of tenecteplase reduces early death and hemodynamic decompensation in normotensive patients with intermediate-risk pulmonary embolism, but increases the risk of major hemorrhage and stroke, according to a study published in the April 10 issue of the New England Journal of Medicine.

Guy Meyer, M.D., from the Hôpital Européen Georges Pompidou in Paris, and colleagues randomized 1,005 normotensive patients with intermediate-risk pulmonary embolism due to right ventricular dysfunction and myocardial injury to tenecteplase plus heparin or placebo plus heparin. A composite of death or hemodynamic decompensation (or collapse) within seven days of randomization marked the primary outcome.

The researchers found that death or hemodynamic decompensation occurred in 2.6 percent of the 506 patients in the tenecteplase group versus 5.6 percent of the 499 patients in the placebo group (odds ratio, 0.44; P = 0.02). Death occurred in the first seven days in six patients in the tenecteplase group and nine patients in the placebo group (P = 0.42). Extracranial bleeding occurred in 32 patients in the tenecteplase group and six patients in the placebo group (6.3 versus 1.2 percent; P < 0.001). In the tenecteplase group, 12 patients had a stroke (2.4 percent), of which 10 were hemorrhagic, compared to one patient with hemorrhagic stroke in the control group (P = 0.003).

"In patients with intermediate-risk pulmonary embolism, fibrinolytic therapy prevented hemodynamic decompensation but increased the risk of major hemorrhage and stroke," the authors write.

The study was funded in part by a grant from Boehringer Ingelheim.

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AAFP Provides Tips to Address Patients' Vaccine Concerns

  
  
  
Physicians must be prepared to explain the risks and benefits of vaccinations

MONDAY, April 14, 2014 (HealthDay News) -- Physicians remain the biggest influence on whether patients get vaccinated, and must be prepared to address patients' reservations, according to an article published in the March/April issue of Family Practice Management.

Marie T. Brown, M.D., from the Rush University Medical Center in Chicago, and colleagues describe tactics to effectively communicate the risks and benefits of vaccination to patients who express uncertainty about vaccines.

The authors write that physician recommendation is the most important factor influencing a patient's decision to be immunized. Practices should make immunizations a priority and include nurses in an advocacy role. Other reasons patients decline vaccinations are the mistaken beliefs that they are healthy and can naturally fight infections; that they or their child will get the illness from the immunization; that there is little threat of the disease anymore; and that the immunization is part of a conspiracy. Physicians' practices need to take into account patients' socioeconomic and cultural backgrounds and should always be prepared to suggest some trustworthy information sources.

"Only by developing a trusting relationship with our patients will we learn of their concerns, be able to address them, and hopefully continue to help our patients avoid these devastating but preventable diseases," Brown and colleagues conclude.

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Patients Select Fewer New Docs at Bottom of Tiered Ranking

  
  
  
Tiered networks combined with payment-based reforms can improve performance, authors say

MONDAY, April 7, 2014 (HealthDay News) -- Patients are less likely to select a new physician ranked in the bottom of a tiered network, but often don't switch if their current physician is ranked at the bottom, according to research published online March 11 inHealth Services Research.

Anna D. Sinaiko, Ph.D., and Meredith B. Rosenthal, Ph.D., both from Harvard University in Boston, estimated the impact of tier rankings on physician market share among both a plan of new patients and on the percent of a physician's patients who switch to other physicians.

The researchers found that physicians in the bottom tier (least-preferred), particularly certain specialists, had a lower market share of new patient visits than physicians with higher tier rankings. Patients were more likely to switch health plans if their physician was in the bottom tier, but patients did not switch away from physicians whom they'd previously seen based on tier ranking.

"The effect of tiering appears to be among patients who choose new physicians and at the lower end of the distribution of tiered physicians, rather than moving patients to the 'best' performers," the authors write.

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Fewer Americans Overwhelmed by Medical Bills

  
  
  
Reduced use of medical care, early health care reforms may be easing financial worries

WEDNESDAY, April 9, 2014 (HealthDay News) -- While millions of Americans still feel hamstrung by medical expenses, a new government report shows that some people are getting relief.

The share of people under age 65 in families reporting problems paying medical bills in the past 12 months dropped from 21.7 percent in the first half of 2011 to 19.8 percent in the same period in 2013, according to the U.S. National Center for Health Statistics, which is part of the U.S. Centers for Disease Control and Prevention. That still leaves 52.8 million people who say they or members of their families were having problems paying medical bills, or were unable to pay those bills, in the past year.

The report draws data from the long-running National Health Interview Survey, which collects health information from family members in each surveyed household. The new analysis is based on household interviews with nearly 227,000 people.

"Almost five million fewer people than two and a half years ago are in families having problems paying medical bills," report co-author Robin Cohen, Ph.D., a statistician with the U.S. Centers for Disease Control and Prevention, toldHealthDay.

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6 Best Tips to Boost Your Documentation Process: Tip 2

  
  
  

documentation tipsGood documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach. In this 6-part series, each Thursday, I’ll be sharing my most recent documentation tips.

 

by: Timothy N. BrunDage, M.D., CCDs

2. Acute MI ICD-10 Update
Acute MI will default to STEMI. AMI documentation must be more specific to either STEMI or NSTEMI. ICD-10 Guidelines dictate that all unspecified AMI will default to STEMI.
• AMI type 2 must be further specified to NSTEMI
• Unspecified AMI default to STEMI could negatively affect quality metrics
• Always document the site of MI if known (anterior wall, interior wall, etc.)
• Always document the age of the MI
• ICD-10 uses four weeks to distinguish between acute and old MI (previously eight weeks with ICD-9)
• Subsequent myocardial infarction is an MI after four weeks

brundageTimothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine

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High-Fat Diet Tied to Certain Subtypes of Breast Cancer

  
  
  
High intake of saturated fat increases risk of HER2-negative, ER/PR-positive disease

MONDAY, April 14, 2014 (HealthDay News) -- High intake of saturated fats is associated with increased risk of certain subtypes of breast cancer, according to research published online April 9 in the Journal of the National Cancer Institute.

Sabina Sieri, Ph.D., of the Fondazione IRCCS Istituto Nazionale dei Tumori in Milan, and colleagues analyzed data from a prospective cohort of 337,327 women to assess the association between fat intake and development of breast cancer subtypes.

The researchers found that high intake of fat was associated with increased risk of estrogen receptor (ER)-positive, progesterone receptor (PR)-positive disease, but not ER-negative or PR-negative disease, for the highest versus lowest quintiles of total fat (hazard ratio [HR], 1.20; 95 percent confidence interval [CI], 1.00 to 1.45) and saturated fat (HR, 1.28; 95 percent CI, 1.09 to 1.52). High intake of saturated fat was associated with significantly greater risk of human epidermal growth factor 2 receptor (HER2)-negative disease.

"High saturated fat intake particularly increases risk of receptor-positive disease, suggesting saturated fat involvement in the etiology of this breast cancer subtype," the authors write.

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Innovation: The Heart and Soul of EmCare and Medicine

  
  
  

Innovation seriesThis post is part of EmCare’s 4-part Innovation series where we highlight what innovation means to members of EmCare’s leadership. Follow this series each Tuesday to discover our commitment to innovation in health care. 

 

By Thom Mayer, M.D. Emcare Executive Vice President

EM for Innovation

Innovation is all the rage these days. The October 2013 issue of Harvard Business Review’s cover story was “The Radical Innovation Playbook: How to Engineer Breakthrough Ideas.” Consulting companies such as Accenture have placed a major effort on innovation for their clients. And innovation had clearly made its way into healthcare, with Duke, Kaiser, UCLA, The Cleveland Clinic, and others forming innovation teams to accelerate the pace of change in their organizations. And EmCare’s 2013 strategic planning meeting was largely focused on how best to innovate and implement (a key word we will come back to it repeatedly) strategies that differentiate EmCare and transform our practices.

Innovation is not new - it is the heart and soul of medicine and the future of our clinical practices. It must focus on improving patients’ lives, improving the lives of those who care for the patient, and creating hope for the future of both. But innovation without implementation across the entire practice is a waste of time, energy, and resources. It is important to understand the mission, vision, and strategies as the context in which the innovation efforts are embedded. Without that context, innovation can seem disruptive simply for the sake of disruption and not as serving the core values we hold.

I believe healthcare innovation must be driven by three other reasons:

  1. Measurably improving both the clinical and service outcomes for our patients
  2. Making the job of doing so easier for our physicians and clinicians who provide that care
  3. Creating hope for the future of our Practices

Let’s consider each one of these.

First, the patient always comes first, and our innovation efforts must always keep that at the forefront of our efforts. Whether clinically or from a service standpoint, we must always ask, “How does this benefit the patient?” And if it doesn’t benefit the patient, why are we doing it? we should be unafraid to make the results of our performance transparent and open to analysis on how they can be improved.

scribesSecond, we must also consider how we can make implementing those best practice innovations in a way in which it makes our jobs easier, not harder. Implementing scribes is an example of an innovative solution that benefits the patient and those who care for the patient.

Third, what do I mean by “creating hope for the future of our practices?”

Most of us would agree that there are fundamental elements of our daily practice which, despite our passionate commitment to our patients and their families, are sources of major dissatisfaction. We need only think about boarders, delays, bottlenecks, and shortages in order to remind us of how frustrating our lives can be on a daily basis. That requires a combination of a somewhat maniacal commitment to implementation and audacity.

One of the earliest examples for emergency medicine is an evidence-based approach to patient safety called “Creating the Risk-Free E.D.” (CRFED) CRFED is a protected, internet-based educational protocols comprising roughly 30 of the most commonly encountered and high-risk clinical entities in emergency medicine.

Following the implementation of the CRFED concept, our loss runs, loss reserves, and malpractice insurance premiums dropped 70 percent! The CRFED program now comprises both adult and pediatric modules, as well as a “Nurse’s Guide to the Risk-Free E.D.,” since it is critical that our nurses know how we intend to approach and treat these patients.While watching David Letterman’s “Top 10” list one night, it suddenly struck me that we already know the “Top 10” clinical entities constituting our risk of having a malpractice suit filed against us. Why not risk-proof our practice by developing evidence-based approaches to these patients and assuring that all of our clinicians were exposed to them and complied with them.

Mayer for InnovationDr. Thom Mayer is founder and CEO of BestPractices®, Inc., an EmCare affiliate, and executive vice president of EmCare. Dr. Mayer is recognized as one of the nation’s foremost experts in leadership and management in emergency medicine. His work has been recognized by the American College of Emergency Physicians (ACEP) as well as the American College of Healthcare Executives (ACHE). Dr. Mayer has twice been honored by ACEP as its Outstanding Speaker of the Year and three times for its “Over the Top Award.” He has lectured on key clinical and leadership issues for ACEP for each of its past 32 Scientific Assemblies. He is the Keynote Speaker for ACEP’s Emergency Department Director’s Academy (EDDA) and is the chief editor of the landmark textbook, Emergency Department Management: Principles and Practices. He has also written Leadership for Great Customer Service, Hardwiring Flow, and Leadership for Smooth Patient Flow, the latter of which won the 2008 James Hamilton Award from ACHE for the best book on healthcare leadership. Dr. Mayer is also the Medical Director for the NFL Players Association, where his work on concussions has transformed the understanding of sports concussions.

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RELATED ARTICLES:

EmCare 2013 Genesis Cup Winner featured in Becker's Hospital Review  

Innovation Series Part 1: EmCare Increases Its Focus on Innovation

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