The Rise and Potential Consequences of Using Advanced Practice Providers

Utilization of APPs (advanced practice providers) or MLPs (mid-level providers) such as nurse practitioners and physician assistants, has increased geometrically all across the medical field. The APPs have filled huge gaps in medical care and have performed quite well. However, with growth comes the concerns and responsibilities of supervision, training, continuing education, and liability.

The recent article Medical Supervision of Mid-Level Providers written by a malpractice insurance company contains an extensive list of concerns. They are:
·         Ensuring proper credentials.
·         Delineating scope of practice.
·         Being sure a MLP’s clinical activities do no exceed the supervising physician’s Clinical privileges.
·         Teaching sufficient communication skills to the MLP.
·         Conducting regular and periodic reviews of the MLP’s activities and clinical responsibilities.
·         Encouraging each MLP to seek supervising physician oversight as needed; encouraging questions.
·         Require MLP badge identification to make credentials clear and avoid misunderstanding.
·         Provide patients a mechanism to access the supervising physician, if they choose or request.
·         Be familiar with local laws related to the scope of practice and supervision requirements for MLPs.
·         Be sure each physician who oversees MLP activities is authorized/approved to provide supervision.
·         Ensure that the MLP is properly trained for the nuances of your individual practice setting.
·         At least yearly, review/update MLP job descriptions, policy statements, practice protocols, collaborative and employment agreements.
·         Keep a copy of the collaborative agreement on file in each practice location where the MLP works.
·         Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
o    Identify the supervising/collaborating physician(s);
o    Identify the types of medications to be prescribed as well as limitations;
o    Define provisions for managing emergencies; and
o    Specify the frequency of reviewing prescriptions written for controlled substances.
·         Regularly review and update protocols for frequently encountered clinical problem(s).
·         Plan scheduled meetings with each MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
·         Document any clinical problems discussed and a plan for improvement.
·         Be sure that professional liability insurance includes coverage for MLPs.
·         Contact your malpractice carrier immediately whenever adding MLPs.
 
While this may seem to be quite an extensive list, it is actually the same general conditions under which most physician providers function. Additional suggestions are:

1.    Make sure that the chain of responsibility of the supervising physician is specifically spelled-out, and understood by all.

2.    Be careful of having different malpractice vendors for MLPs and supervising physicians. This can generate adversarial situations when a case appears.  
3.    Have clear, specific policies regarding when the MLP should ask for an immediate consultation.
4.    Make sure APPs do not identify themselves as doctors, even if one has a PHD. Juries are sensitive to potential misrepresentation.
5.    Send your APP to specific courses for the care setting in which you work. Remember how practical knowledge comes with time, but is not innate.
6.    Understand your malpractice coverage. A consultant may help make sure everyone is adequately covered. The APP needs to be named on the policy.
7.    Have a cordial and professional relationship with your APP.
8.    Avoid allegations of fraud by following CMS billing guidelines; your degree of clinical involvement in any case should never be overstated.

Times are changing and it is important to adapt to the new realities. The Advanced Practice Provider is the political answer to lack of access to health care for the near future.

The Role of the Provider in Triage

The proposed addition of a physician’s assistant or nurse practitioner at triage adds a new wrinkle in the fabric of patient processing. The political and administrative motivation to do so is usually an external demand to achieve “door to provider” times of less than 30 minutes. If claimed by a hospital, usually in the form of “see the doctor within 15 min or less,” it is a powerful advertising tool.

The clinical benefits of adding a high-level provider at triage include immediate reliable assessment, pre-ordering of tests, and direct, speedy, discharge of minor problems.  The upside to these is the potential to create often needed space in the ED and/or waiting room. The downside is that these results provide no guarantee that average patient LOS will be any shorter than if triage were performed by a qualified nurse or other non-physician staff.

Q&A

Q: What kind of provider is necessary out in triage? 

A:  At minimum, triage requires a highly skilled physician’s assistant or nurse practitioner, with extensive experience, who understands the clinical needs and operational characteristics of the particular ED in question. Since an associated goal is to also improve the patient experience and ultimately his/her satisfaction, the personality characteristics of the triage provider are essential. Optimal personalities do not “grow on trees,” yet even if uncommon, one would look for those who exhibit a “gentle touch,” a welcoming, understanding manner, and an ability to skillfully handle the stresses of triage.

Q: Can a physician do this job?

A: Yes, but it is expensive and some, perhaps most, physicians are better suited to encounter (conscious) patients after other staff has done the initial meet, greet, & initiate functions.

Q: How much of a work-up is needed from triage?

A: As usual it depends on the presentation and context.  If space is an issue, the proper ordering of tests can lead to prompt disposition (admit or discharge) shortly after the treating provider arrives to see the patient (1 stop-shop). This works in even complex patients, if an excellent triage provider orders the appropriate tests and initiates key treatments. Whether one test or multiple tests are needed, the treating provider can often make a final disposition (“close the deal”) if results are back and response to treatment can be assessed at the first physician encounter.

Q: What about flow?

A: A good working relationship between the triage provider, and the charge nurse can significantly benefit patient flow through an ED.  Communication between triage and the unit are key to quickly identifying patients at high risk and making appropriate and efficient bed assignments.  While the standard use of 5-level triage has some value, it is not subtle enough to make distinctions between those in the middle, who are often gray-zoned until results come back. That is, not all 3’s are equal; after the dust settles and tests are back, many middle tier patients can be sent to Fast Track or discharged without even being placed in a bed.

Q: What’s the bottom line?

A: The triage provider needs to be an exceptional, dynamic, individual, one with extensive clinical experience, who can not only multi-task but is also able to function as an ED Flow expert.

RVU’S ‐ Successes, Perils and Pitfalls

RVU Components

The RVU (Relative Value Unit) is becoming an important consideration for ED physicians. Its original intent was to become a standard measuring tool for incentivizing clinicians toward increased productivity.

CMS assigns an RVU value to every CPT code, using 3 components:

1. Work –55% ‐ with five sub‐components:
• Time
• Mental effort and judgement
• Technical skill
• Physical effort
• Stress
2. Practice expense ‐ 42% ‐to account for overhead to run the practice / manage the entity to which the CPT code refers (does not include the EMTALA effect)
3. Professional liability‐ 3% ‐ allotted to “address” the cost of malpractice insurance.  Applied at 3%, even if actual PL costs are 1%, 10%, or 50%.

Rationale for RVU Incentivized Programs

 

The rationale for an RVU incentivized program is to increase the overall efficiency of the provider staff by rewarding efficiency. In theory this tool will stimulate clinicians who are marginally efficient, or less than optimally efficient, to improve by linking rewards to performance.

Again in theory, CMS hopes to decrease its (endangered) costs for services by stimulating efficiency. Physician groups would correspondingly hope to gain profitably by improving patient flow.

In an ideal world, this would be a win‐win situation for both CMS and clinicians.

RVU Implementation Systems

There are essentially two ways to implement an RVU system.

The first uses 100% RVU reimbursement, also known as “eat what you kill.”

The second guarantees a base salary; to that base is added a “piece” of the group’s overall RVU pie; the size of each piece is determined by the individual’s percentage contribution to the total RVU pie. Other factors may be given value in either methodology, so that RVU credits can additionally be offered for positive patient satisfaction scores, meeting attendance, night shift differentials, absence of complaints, participation on committees, etc. RVU credits may be subtracted for such things as above average number of complaints, failure to complete charts in a timely fashion, lateness, or other negatives that impact the group’s image or performance.

RVU Program Pitfalls

The unintended (and therefore problematic) consequences of an RVU program are especially evident in three areas:   

1. Competition between physicians
2. Potential for some to game the system
3. Invisible impact on departmental workflow

Competition occurs when clinicians attempt to sequester certain types of (higher RVU) chief complaints, and maintain control of their progress principally for the benefit of their own bottom line. Such activities may become evident as general attitude changes, cherry‐picking of chief complaints, evading of opportunities to pitch‐in and help when these do not directly impact one’s RVU tally, chart hoarding, and others.

Gaming the system has various forms, including uneven use of practice assets (PAs, NPs, scribes), requisition of choice shifts, buffing critical of care charges, working unpaid hours, and others.

Impact on ED Workflow may be unapparent but significant. When the analytic focus is on just RVUs, they become a somewhat distorted numerical representation of efficiency. Other major factors may be hidden by the dominance of the RVU process. Such hiddenness may be of greater consequence in a big department, where some physicians may perform non‐RVU activities that facilitate and support essential ED functionality.

For example a “fast” ED physician who can clear out the waiting room and the incoming queue by seeing a load of “lower value” RVU patients, opens up the department in key ways that enable the influx of higher RVU value patients. In the final calculation, in this case, the clearing physician is of inestimable value, while it is the other physician who gets the RVU credit, creating an imbalance that does not represent true value.

The Solution

Ultimately, it takes sophisticated analysis and constant adjustment to make such a system work. It will not be a walk in the park. Attention should be paid to the cumulative acquisition of know‐how about RVUs and applying them most appropriately for your particular ED and its physician staff.

The best solution might be a combination of equal shares of:

1.  Base Salary
2. "Eat what you kill" - minus practice expense of PA's,NP's, and scribes
3. Rewards for intangibles
• performance metrics (door-to doctor/door to balloon/LOS etc
• patient satisfaction scores
• complaints and compliments
• meeting attendance/committee participation
• risk management CME's
• quality measures (how to measure?)
• resource utilization and consumption

• 
  

The Value of Discharge Instructions

The purposes of discharge instructions are:

• To provide time-specific follow-up with the appropriate family physician or specialist
• To  convey to the patient and/or family some knowledge of the probable disease or injury process
• To list prescriptions and treatments given
• To establish a layer of medical-legal protection for the practitioner 

At minimum, instructions need to be legible, and so are best computer generated and printed.

Unfortunately, however, unintended consequences of these efforts have evolved into a complex morass of endless paperwork.  As a result, the patient now receives a bundle of pages equivalent to a small textbook, containing more information than most people can realistically comprehend, including drug interactions, side effects, multiple contingency plans, and complex symptom sets to watch for.

The KISS (Keep It Simple Stupid) principle should predominate.  

Most importantly, the patient and family need to know that he/she should comeback, or be brought back, immediately if there is any deterioration or if new symptoms have developed. This bottom-line principle message needs be stated concisely in fourth grade level language, using large readable letters.

What to Do About PAIN in the ED?

The treatment of chronic pain has become a very complex and hot topic for providers. Little or no controversy exists about the treatment of acute pain; one just treats as necessary.  Acute exacerbation of chronic pain is also less clear.   

The goal is to treat patients humanely and appropriately without facilitating drug dependence and drug trafficking.

The pressures are complex and complicated. On the one hand, are those forces that make a physician more reluctant to prescribe pain medication, including:

1. States have created databases that keep, and make available online, records of all controlled medications prescribed, including the DEA number of the prescribing provider

2. Certain states, such as Florida, now require special licensure to treat non-cancer pain chronic pain.

3.Peer pressure from colleagues and support teams who feel everybody is a potential abuser. This puts certain patients with severe, painful conditions in the assumed category of “potential drug abuser”.

On the other hand, the real-time daily forces of clinical practice lead one to be less restrictive in administering pain medication. These include:

1.     CMS has made pain a de facto “vital sign” that must be addressed and documented.

2.     Patients request pain relief for a variety of complaints that are often very reasonable.

3.     Patient satisfaction scores like PRC and Press-Gainey emphasize pain relief. These scores affect contracts, RVU’s and levels of complaint to administrators. The #1 complaint in our ED is that the doctor was insensitive to pain relief and refused treatment.

What should one do? It is indeed a challenge to find a balanced, thoughtful approach trying to blend the various demands into a reasonable outcome. Our ED actually considered hiring its own pain specialist to deal with these endless problems.

Time----Time---Time

Time to click—Time to task—Time to everything

The modern tracking board has allowed the provider, the hospital consultants, administration to time multiple events in the ED.

The tracking board can be used to calculate

1.     Door-to- Provider

2.     Provider to Decision

3.     Decision to Admit

4.     Decision to Discharge.

5.     Door- to End of Event –LOS

6.     Last Lab to decision

7.     Last x-ray to decision

8.     ETC/ETC/ETC

Using Lean-Six Sigma techniques the ED efficiency can be improved dramatically. The only problem that “quality” is rarely brought into the mix. It is implied that “quality care” is fixed quotient without any variables that can be reproduced in the same time frame every time. After practicing more than 30 years, I am consistently surprised by certain events, results, and outcomes.

"Let the TRACK MEET begin”.

Doctor Aware” - The Integration of Nursing Notes and Physician Documentation

How does the provider keep track of the nursing notes with the use of purely electronic medical records?

         

Theoretically, in the “paper world” the provider would read all the nursing notes and then comment or appreciate the content. In reality, the provider rarely reads more than the initial triage assessment and nursing note. The rest of notes are kept with the nurse and usually completed long after the physician is finished with their documentation. Physicians who document after the fact on their own time, may or may not use or have access to the notes.

         

In the “Electronic World” the provider rarely has real-time access to the nursing notes with a single mouse click. They have to maneuver around the program to find the data (if it even there yet). Your computer program should have easy access of all data to all providers that have been granted access. This should be accomplished easily and without requiring the user to be a computer expert.

Additionally, how do healthcare providers know when the nursing notes are complete concerning the interaction with a specific provider? The notes can go on and on for “ED Boarders” when the initial provider is long gone. This is also true for discharged patients when the nursing notes are done long after the fact.

My favorite nursing notes are “Doctor aware” and “Doctor notified”. About what?????

The EMR we use attempts to solve some of these problems with simple interface like a “tab button” that allows quick access.

2 Hour Length of Stay in the ED - Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or less no-wait ED service.

The implication is a provider (physician, PA, or NP) will greet you- a la the Wal-Mart greeter- to begin the service relationship. There are billboards, internet advertising, etc. that proclaim your care will be improved because it will be faster.

If properly conducted where the patient is fully evaluated, there should be significant PRC or Press-Ganey score improvements.

I would prefer to see the metrics based on speed, quality, and outcome.

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The provider will discharge, admit, or carefully discuss with the patient and family the “Battle Plan” for disposition at the 2 hour mark.
1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient.
         a. Outline the timeframe
         b. Discuss need for more tests (CT abdomen)
         c. Waiting for consultant
         d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of              troponin levels

Medication Reconciliation and E-Prescribing

E-prescribing is a certification requirement for out-patient clinics and urgent care facilities for EHRs to obtain "meaningful use" monies from the government. E-prescribing is desirable for patients, but its real objective is medication reconciliation.

This process is intended to be convenient for the patient; however, there is also an underlying goal to achieve medication reconciliation. The goal of medication reconciliation is important, but it is also time-consuming and labor intensive.

The problems associated with e-prescribing are:

• Who is going the input the info?
• Who is going to keep it updated?
• What is the time frame?
• Accuracy depends on patient and data collection

E-prescribing can only be accomplished if medication reconciliation is performed by the E-prescriber and his/her software. This puts the burden on provider and his/her staff.