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

Guest Blogger - Jim Tate: EHR Incentives Drop Dead Dates

Several times a week I am asked the same question by providers and vendors. The question takes different twists and turns, but it all gets down to one core concern. To put it in the crassest terms, here it is. “What is the absolutely last drop dead date an eligible professional can meet the CMS EHR Incentive Program requirements and not leave any money on the table?” OK, now that the question is clear, let’s answer it once and for all.

For Eligible Professionals there are two CMS programs, Medicare and Medicaid, which incentivize EHR use. An EP must select one of the programs for participation, and is allowed to switch programs once. Let’s take a look at Medicaid first. 2016 is the “Last year to initiate participation in the Medicaid EHR Incentive Program” and 2021 is the “Last year to receive Medicaid EHR Incentive Payment.”

To continue reading this blog visit: http://www.hitechanswers.net/ehr-incentives-drop-dead-dates/

Jim Tate is a nationally recognized expert on the CMS EHR Incentive Program, certified technology and meaningful use and a partner in HITECH Answers. He is also author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1.

HITECH Answers - www.hitechanswers.net

To purchase Jim Tate's book "The Incentive Roadmap The Meaningful use of Certified Technology: Stage 1 visit:  http://www.hitechanswers.net/products-page/

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.

Liability and the Electronic Health Record

The electronic health record (EHR) should lead to patient safety and help minimize liability, but there are built in-traps that come with it. These traps can be subtle and can lead to quality reviews and potential liability for the provider.

Potential Traps:

1.      Timestamps—all over the place. These can be recorded but may not necessarily reflect true clinical activities. Not paying attention to document when things really happened.

a.      EKG was signed off 1 hour after the patient was already in the cath lab

b.      Clinical course out of sequence with CPOE and nursing notes

c.       When a consultant was called  and their advice

2.      “cut and paste”---“cut and paste”  Copying and pasting information can be as harmful as it is helpful. Information can easily be repeated or copied into the wrong section.

3.      “Cookie-cutter” charts that are  loaded with data that may or 

      may not have occurred.

4.      Inability to easily access nursing notes- and the converse. The world famous “DR aware” note.

5.      Not knowing the status of treatments orders, even though the computer says they are signed off.

6.      Clerical errors on the CPOE.

7.      Not creating a work-flow that emphasizes timed data points that affects LOS/time to provider/time to decisions. If the providers are not “clicking” the tracking board, the     data suggests inefficiencies. Hospital management only looks at the data and rarely any excuses.

8.      Timelines are much easier for the plaintiff's attorney to create, which may look jumbled even though the reality was different.

9.      Not checking the output on key areas to make sure it reflects what was supposed to be communicated.

10.  Receiving a transfer patient with “40” pages of computerized documentation and missing the key.

Dictation Software - The Best Way to Avoid Traps:

In the clinical course, use dictation software or voice-activated technology to create a recap of all the events. I prefer to use Dragon Medical dictation software. A quick summary will indicate the battle plan, the response, and the disposition.

Paper, dictated, and electronic charts are all good for the initial evaluation and the disposition, but the clinical course is usually murky and left up to the imagination.

Does Medicare Reimburse for “Pharmectomies?"

Living in Florida, we see large number of elderly, chronically-ill patients with multiple medical problems.

These patients have multiple providers – primary provider, ED provider, nursing home provider, hospitalists, consultants, etc.

This leads to multiple treatments and prescriptions that have endless interactions and reactions.

After the medication reconciliation is completed on the Electronic Health Record (EHR), the process does not simplify.

So we have changed our process at my ED. Now if your medication bag weighs more the 5 lbs., we admit that patient to the hospital for a “Pharmectomy” - we eliminate all the medicines and start over. 


We are currently searching for a “surgical code” for this procedure as the reimbursement might be higher. 

Why has the Most Expensive Person in the Room turned into the “Data Jockey?"

In the old days, the healthcare provider would scribble a few orders, write a brief note and be done with the paperwork.

Times have changed.

When using a tracking board, CPOE, and Electronic Health Record, the healthcare provider is now burdened with inputting endless data to obtain accurate:

•               Through-put times
•               Door-to-balloon times
•               Stroke alert data
•               Time of EKG reading
•               Time of consultation
•               ETC., ETC., ETC. – The list is endless

This does not include the history and physical, clinical course, medical decision making, procedure notes, critical care documentation, Rx, and discharge paper work, and etc.

What kind of help is available?

• Scribes work but are expensive.
• Voice activated input like “Dragon Medical” dictation software   are worth every penny
• A data gatherer who sets up record with everything except  HPI and MDM (college students are inexpensive)
• You could do everything after the fact but times are inaccurate depending on the program used. This practice also burns providers out and increases the need for mental days off.

The provider is “bogged down” with endless paperwork regarding data entry which leads to lost productivity and less real-time patient contact and care. Switching to an EHR will take some adjustment time but it will help healthcare providers adjust to the role of  “data jockey.”


My ED uses a combination solution.

• The king pin is an EHR charting program, XpressCharts EHR, that I helped developed. The program is user friendly, has the ability to created “favorites,” is dictation software compatible, and has a minimal need for user computer knowledge. The program can also be used easily without adjuncts.
• Voice activated support that allows users to dictate in all text boxes. The EHR used, XpressCharts EHR, is set up to easily allow this which eliminates most typing.
• College students serve as “data-go-fors”.

Treatment Protocols, Cookbook Medicine, and the Food Network

Treatment protocols for Sepsis, ACS, STEMI, GI Bleeding, Coagulopathy, Hypertension, Pneumonia, etc. have been created to aid the clinician in giving the best evidence-based treatment plans. These can be attached to the CPOE and be used easily. The advantages are not “reinventing the wheel”, using UTD treatment plans or bundles, and give the support staff parameters of how to adjust the medicines per response of the patient.

        

Criticism has arisen because this is cookbook, formulaic medicine that is unnecessary and intrusive, making the individual feel his/her plans are 
superior.
   
Our ED group has chosen to emphasize protocols for critical patients to give the patient the best statistical shot at success.

Being a fan of the Food Network and their creativity, it is apparent that cooking is a function of chemistry.  All the great cooks use basic protocols (recipes) to get started and adjust them with nuance and art.

The same can be done with medical protocols when they are used as a basic approach. The “Art of Medicine” (experience, knowledge, empathy, spirituality, gestalt) can then be added to make the protocols “state of the art”.