The changes sweeping through health care are evident in the lectures planned for emergency medicine's largest conference this year. From presentations on observation medicine and boosting ED efficiency to coping with shift work and using social media, the annual Scientific Assembly of the American College of Emergency Physicians Oct. 8–11 in Denver promises to connect emergency physicians through workshops, lectures, and posters.
Conquering the Moguls of Healthcare Reimbursement Wednesday, Oct. 10, 10 a.m.
When does a carrot become a stick? When pay-for-performance becomes a fact of life for emergency physicians — a day that has arrived. “It's really here,” said Michael Granovsky, MD, an emergency physician who is the president of LogixHealth, a coding and billing company for emergency departments.
His lecture at the American College of Emergency Physicians' Scientific Assembly, on the evolving landscape of the health care system will cover current and pending reimbursement changes stemming from the Centers for Medicare and Medicaid Services (CMS) and the Patient Protection and Affordable Care Act (PPACA). “You need to look at PPACA and the onslaught of CMS programs to know what you and your group will be confronted with to prepare and develop strategies for success,” he said.
Dr. Granovsky's session offers a few advisories, some of which may sound more like warnings. Private insurers are pressuring employers and patients to obtain care in lower cost centers, he explained. Metrics, benchmarking, risk adjustment, and comparative effectiveness are increasingly influencing reimbursement for government and private payers — and are likely to be even more important in the future.
How will all these data be collected? CMS aims to identify and reward the most efficient hospitals and health care providers based not just on good outcomes but on the most cost-effective ones, too. These reportable rates of hospital readmission reduction and hospital-acquired conditions will affect day-to-day practice. So will scores from a standardized survey on patient satisfaction, the Hospital Care Quality Information from the Consumer Perspective (HCAHPS). These data, including the HCAHPS, are — or will be — publicly available through hospital and physician-comparison websites.
A value-based payment-modifier also will affect all Medicare reimbursement, he pointed out. But a silver lining may be in store for emergency medicine, Dr. Granovsky said. “Hospitals will now have ED throughput measurements,” he noted. Departments that have struggled with crowding may now have a revenue-producing incentive for hiring additional staff and streamlining patient flow. “You don't have to be a victim,” he said. “Learn how to shape your practice to be a winner for 2013 and beyond.”
ED Overcrowding Workshop Monday, Oct. 8, 12:30 p.m.
Another change will be the rise of “observation medicine,” which increasingly will be seen in EDs, predicted Peter Viccellio, MD, a professor and the vice chairman of emergency medicine at the State University of New York's Health Sciences Center in Stony Brook, NY.
That means extended treatment for patients who would otherwise be low risk, and short-stay admissions “will become the central player in cost containment and improving inpatient capacity,” he said.
Dr. Viccellio, one of the panelists along with Eddy S. Lang, MD; Grant Innes, MD; Zina Semenovskaya, MD; and Peter C. Wyer, MD, will help “set the table by talking about common challenges and solutions” to these changes and address issues of practice that affect capacity, he said.
“Attendees will learn from each other by sharing their own experiences with ED crowding, what changes they've seen that succeed in assisting flow, what strategies haven't had much effect,” he said. The workshop discussion “provides some of the real and practical answers about ways to improve it and how to overcome barriers to change,” he said.
Observation medicine in the ED is one of “the profound, sweeping issues that will change capacity, as well as the scope of practice for the emergency physicians,” Dr. Viccellio said. Cases of cellulitis, pyelonephritis, acute asthma exacerbations, chest pain, syncope, and transient ischemic attacks are examples of problems for which patients are often admitted, he noted. Many will instead have their diagnostic workup and treatment in the ED in the future. “Insurers, including the government, are beginning to refuse payment for admission of some of these patients, a trend likely to grow,” he added.
There's An App for That Wednesday, Oct. 10, 12:30 p.m.
Conceptually, “small devices help us overcome hurdles to care,” said Joshua Broder, MD, an associate professor and the associate residency program director at Duke University Medical Center in Durham, NC.
Technology that pares down periods taken up with time-stealing tasks such as documentation and venipuncture may increase time for other uses such as physician evaluation. Time-savers include point-of-care devices from bedside ultrasound for no-wait diagnostic imaging to cordless intraosseous drills for infusing medication. The big advantage is that they are faster to use, he said. “If I have a patient with nine different symptoms, I can draw blood or check a chemistry panel quickly this way,” said Dr. Broder, noting that this frees up time for thinking about what patient complaints actually mean instead of simply acting on them.
“It is our cognition that's required to analyze clinical problems, and our availability for doing that needs protection,” he said.
Some precautions are needed for utilizing this technologic wave. Have a patient with a forearm lesion you need to show a dermatologist for a quick consult? The photo-taking, Internet-connected cell phone yields a “new level of communication,” in which an image of the skin eruption can be emailed rather than the old-fashioned way of laboriously describing it.
Be careful with photographs of patients, however, Dr. Broder said. “You download some photos to send friends, and suddenly, along with vacation pictures of your kids playing in a pool, you've got this arm in there,” he said. “And if the arm has a tattoo, you could have a HIPAA violation” because now the limb may be considered identifiable. He has adopted a rule for clinical information collected this way: Purge it immediately or send it to a “safe file” elsewhere. Letting such data accumulate in a smart phone creates risk, he warned.
Starbucks, Stairmasters, and Sleeping Pills Thursday, Oct. 11, 10 a.m.
Emergency physicians need to watch the clock in ways few other professionals do. No, not that clock — the circadian one.
Disturbance of the circadian rhythm, a side effect of varying shift work, can impair cognition and contribute to stress. Staying on a permanent schedule is just not possible for most in emergency medicine. The good news: sleep loss is modifiable, said Rebecca Smith-Coggins, MD, a professor of surgery in the division of emergency medicine and the associate dean for Medical Student Life Advising at Stanford University.
Her lecture will provide information for maintaining a healthy life amid the challenge of ever-changing ED schedules and demanding late nights, including how to use caffeine strategically and when to catch a quick 40 winks. Brief naps can be restorative, Dr. Smith-Coggins said. A 40-minute nap at 3 a.m. made physicians and nurses working overnight feel more alert at the close of their shifts compared with others who didn't get a nap, according to a study she and colleagues conducted. (Ann Emerg Med 2006; 48:596.) “Even a 10-minute nap may give you that edge,” she said.
Caffeine also can be used advantageously to promote mental sharpness. In fact, coffee consumption was recently linked to lower mortality, according to the National Institutes of Health. A federally funded survey of more than a half-million people 50 to 71 found coffee consumption was associated with longevity, or more precisely, up to a half dozen cups per day were found to be inversely associated with death from heart and respiratory disease, stroke, diabetes, infection, and injuries. Women who drank coffee had a 15 percent lower risk of death and men a 10 percent lower risk, according to the NIH-AARP Diet and Health Study. (N Engl J Med 2012;366:1891.)
Physician wellness is garnering new attention, a trend that seems to have started with limiting duty hours for residents but has expanded into other areas of practice. “Things are improving,” Dr. Smith-Coggins said. Now, there are calls for wellness programs that address shift-work stressors and sleep disruption, with a new emphasis on the role of diet, exercise, social interaction, and other coping strategies. (Acad Med 2012;87:598.)“We need to consider physician wellness an indicator of success,” she said.
Your Wall is Showing Wednesday, Oct. 10, 12:30 p.m.
Dr. Broder speaks again in a lecture about the effective use of social media, and will share information on how to use Facebook and other sites for staying connected socially, a known stress-buster.
Social media also can help emergency physicians stay connected and supported. But when blogging takes place during periods of stress or fatigue, problems can erupt, said Dr. Broder. Blogging or posting to unveil personal thoughts and opinions, particularly those regarding work, can become too revealing, he warned. “The tone of expression is just lost in electronic communication,” he explained. For another, such posts may be seen as enlightening by the writer but as venting by a reader. “You have no idea who your audience is going to be,” he said.
Dr. Broder cited the example of one emergency physician who confessed to needing a stiff drink or two after his shift. “It could be that someone reading that thought: ‘Does this guy always have to drink to cope with the demands of his job? What does that say about him?’”
A good guideline: Don't write when you are tired or frustrated, and don't write anything that your own mother would be embarrassed to read. Keep in mind that patient-centeredness is key. After all, even though work-related postings are able to be deleted, “they can be copied or saved and sent around by others,” he said.
“It is really hard, maybe even impossible, to get rid of something once it is out there on the Internet,” Dr. Broder said. “The easiest way to do that is to make sure you don't put something there that you might regret. You can't really take back things you say that sound differently than you intended. You can say, ‘I am sorry. That didn't come out right,’ but it may be too late,” he stressed.
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