Merit Badge Medicine

In Mel Brooks' 1974 Western Blazing Saddles, he famously misquoted the line, "Badges?  We don't need no stinking Badges!".

In medicine, there is always a debate on whether a provider needs ACLS, ATLS, PALS, etc. to be qualified to obtain employment.  these particular cards have created a "cottage Industry" that relies on new and recertification participants to keep the ball rolling.

There is a need for constant education and preparation, but whether obtaining these certificates imply high quality and standardized abilities is another matter.  The education program is also based on guidelines and opinions that are not necessarily evidence based.

Everyone should know the guidelines who practice Emergency medicine, but do not necessarily need a card or merit badge to affirm ability. 

ACLS (Advance Cardiac Life Support) has come a long way to simplify the process for non-clinicians by eliminating the complexity.  They have also learned that retention of the information is so limited they have installed the KISS (keep it simple stupid) approach to get people to participate.

Providers with board certification in their respective specialties should be encouraged to stay up-to-date, but not necessarily required to have a "Badge".

Migration Issues

 



They are various types of migrations.  We are going to focus on data and system migrations- both have many complex issues.

• Data migration- the process of transferring data between storage types, formats or computer systems.
• System migration - the tasks involved when moving data and applications from current hardware to new hardware.

A new complexity has been added to the Electronic Health Record when practices, hospitals, departments and urgent cares either transition from paper to electronic and/or change products or vendors.  The reason for change include:

1. Adoption of an enterprise system that co-opts prior vendors.
2. Adopting a product for meaningful use funds and/or e-Prescribing.
3. General discontent for the present system.
4. Lack of support from prior vendor.
5. New products have "wow-factors" the save FTEs.
6. New ownership wants to consolidate their practice to one format, etc.

When purchasing a new Electronic Health record, it is incumbent that the "migration" to the new format is planned and supported by the vendor.  These include interfaces to capture old data, scanning solutions, 24/7 support, and a firm understanding by the new provider of the various complexities.

Avoid "re-inventing the wheel" by having these discussions with all parties to provide a smooth transition.  Do not suffer from inertia- the tendency of a body to maintain its state of rest unless acted upon by an external force.  Making changes to improve productivity, work-flow are always in your best interest.

The Right Click Dilemma!

What is the difference between a person who understands computers and the rest of us?  It is the ability to understand that programmers love to right click to create endless contextual menus.  these menus are interpreted by IT people because 1- they know they exist and 2- they read and act on these menus.  The rest of us stare in silence, stupidity, or disbelief.  How did they know"that"?  Why would they hide the menu from us?

When dealing with many Electronic Health Record systems, the right click is your arch nemesis.  You had endless hours of training, but still cannot remember what to do next.  You did not realize that you can right click something or everything and multiple hidden menus appear with the answer.  When you have suffered through multiple minor epiphanies and created multiple "work-a-rounds" and/or "favorites" the program becomes less onerous.

The real solution is end-user friendly Electronic Health Record do not rely on a right click, multiple hidden menus, work-a-rounds, and favorites to utilize.  The user should be able to look at the screen and intuit what to do next.  What is painfully obvious to the "programmer" is not obvious to all end users.

If the program takes endless hours of training, needs "super-users", and you forget things after only 1 week, the endless psychological toll it takes on the users is profound.  This leads to lost productivity, unhappy employees, and general disenchantment with the whole process.  The Electronic Health Record has many potential benefits, but this is often lost in the battle to process efficiently.

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

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