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Medical Staff Bulletin

April 2014

Contents

Message from the Chief of Staff

In last month's Medical Staff Bulletin, we addressed concerns about Epic documentation and challenged clinical departments to convene a task force "to define elements to be addressed in documentation, identify who is responsible and accountable (for such documentation), establish standards and create a review mechanism to monitor documentation quality."

Very recently, at the urging of our Board of Trustees Patient Safety and Clinical Quality Committee, we surveyed several departments about their "standards" pertaining to "attending physician documentation in Epic." One service was exemplary in response to the questions:

  1. When attendings change day to night, night to day, weekday to weekend, is it the practice for the attendings to always indicate that they are attending of record in Epic? Yes. At the beginning of their day, the attendings assign themselves as attending in Epic. Night attendings assign themselves as coverage for patients already in-house and assign themselves as attending on new admissions they perform.
  2. As attendings change with the hand-offs described above, do they always identify themselves to patients as the responsible attending? Every time the attending interacts with patients, they are supposed to identify themselves as the attending, the person in charge of their care. They are also to hand them their large business card.
  3. What is the standard for communication of attending-to-attending with hand-offs? Our standard is the written sign-out in Epic. If physicians need to verbally communicate information, such as the patient needs to be seen soon, they are to do that at the end of their day/shift.
  4. In identifying themselves as the attending of record, do attendings make it clear that they are the focal point for all decisions and communication? The attendings, as noted above, are supposed to state that they are in charge.
  5. When attendings take over cases, do they always indicate in their notes the best way to contact them? At the end of their note in Epic, there is a required *** field in which you must enter your contact information.

We learned the majority of services and departments have no established standards addressing these questions. The surgical services and departments frequently follow patients from admission through discharge, but there is a dizzying array of coverage schemes at YNHH. Attending-to-attending hand-offs and direct communication often do not take place and are delegated to resident-to-resident communication. The latter is extraordinarily invaluable for training and care purposes, but physicians will soon hear that direct communication with potential for meaningful clarification is a hallmark of a High Reliability Organization.

We hear from many patients, some of whom are our trustees, that they and their families are often uncertain which senior physician is ultimately directing their care. This is, therefore, more than an EMR matter and one which every department should address.

Performance Management Update

January 2013 - December 2013
CMS/TJC Core Measures Performance


CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
342/342
100
100
ACEI at D/C
66/74
89
100
D/C instr. given
219/230
95
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
174/187
93
100
Initial (ICU and non-ICU)
Selection Abx
67/69
97
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
379/388
98
100
Abx selection 380/384
99
100
Proph Abx D/C
361/363
99
100
DVT proph given
387/388
99
99
6 am glucose
103/114
90
100
BB Periop period
234/234
100
100
Foley removal POD2
383/394
97
100

Although Yale-New Haven Hospital spends a great deal of time and effort on the Medicare process measures (left), because they are publicly reported and tied to scoring systems, we also pay close attention to other measurement systems that evaluate process and outcomes at YNHH.

First, the University Health System Consortium (UHC) reports performance on 119 academic medical centers that voluntarily submit their data. These peer institution reports provide useful benchmarks for productivity monitoring and process and outcome measurement. Each year, UHC publishes a quality and accountability study which includes performance of participating academic medical centers (n=101) on six domains of quality and safety. In 2012, YNHH ranked at 75/101. In 2013, the ranking improved to 51/101, and we are aiming to do even better in 2014.

Second, The Leapfrog Group started publishing a hospital safety score in 2012 which is expressed as a letter grade. For both publication years, YNHH has received a "B" letter grade. Why is this score important? It is marketed broadly by Leapfrog and occasionally noticed by the press or patients. Up to this point, YNHH has elected not to participate with The Leapfrog Group in self-reporting data because we are feel their methodology is flawed.

When reflecting on these two very different data sets, it raises larger questions about how to assess performance, the validity of different data systems and sources, the application of weighting and risk adjustment, etc. This has become a point of contention for the medical community and has been raised at the national level with the Association of American Medical Colleges (AAMC) and other organizations. This resulted in a position paper published in February 2014 (online at http://www.chausa.org/docs/default-source/advocacy/030514-guiding- principles-for-public-performance-reporting.pdf?sfvrsn=2) that outlines characteristics of better grading systems and how a standardized reporting system could be more useful. YNHH contributed to the authorship of this paper and is hopeful that it will gain recognition. Although some systems are quite useful for the purposes of benchmarking, etc., they may lead to confusion and contradiction in performance reporting. In our quest to improve, it is important that grading and benchmarking systems convey accurate information about our performance.

Please direct any questions to Tom Balcezak, MD, (203) 688-1343.

Prices coming to Epic

Sometime soon, Epic will provide information on Medicare reimbursement rates for laboratory/ blood bank orders. These will be rates for outpatient testing across Yale New Haven Health System. It is important that clinicians recognize these are neither "costs" nor "charges," but simply what Medicare reimburses hospitals for the testing. We considered actually listing our costs, but these vary across YNHHS whereas the Medicare reimbursement rates do not.

Similarly, actual charges could be placed in the system, but these also vary by hospital. These rates will be visible in the inpatient order entry modules.

Clinicians have also persistently asked for this transparency. They are recognizing the intense pressure on organized medicine to control cost, and it is very difficult to control costs without knowledge of relative expenses. While reimbursement rates do not equate with "cost," they are, of course, related and we believe these data will provide considerable insight into how we use these resources. The intent of providing this information, of course, is not to limit what is important to do in the care of patients. That recognized, there is extraordinary individual variation in how physicians approach testing and some of this undoubtedly relates to lack of knowledge of both the utility and expense of what we order.

Overall, prices will be displayed in a simple, clear and unobtrusive way that will not add steps to the ordering process. We will be assessing our progress with this work over the summer and evaluating whether additional services will benefit from a display of publicly available Medicare reimbursement rates. More information about the price display will be available through the Epic log-in screens. We hope clinicians find this information useful. We will welcome your feedback.

New factor concentrate guidelines approved at YNHH

The Transfusion Committees at both YNHH campuses have approved new coagulation concentrate guidelines, replacing the guidelines written in 2008. The new guidelines are posted on the hospital intranet at https://ynhh.ellucid.com/documents/view/132. Or from the Intranet, click on Yale-New Haven, then Policies, then down toward the bottom click on YNHH Factor Concentrate Guidelines.

Highlights of the changes include:

  • The inclusion of Kcentra, a four-factor prothrombin complex concentrate that is FDA approved for urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist therapy in adult patients with life-threatening, major bleeding or in need of urgent, lifesaving surgery.
  • The inclusion of Atryn, a recombinant anti-thrombin product.
  • The revision of recombinant factor VIIa vial sizes, and the inclusion of a black box warning regarding the risk of arterial thrombosis with this drug.
  • The removal of Bebulin, a three-factor prothrombin complex concentrate. For more information, contact Jeanne Hendrickson, MD, associate medical director, YNHH Transfusion Medicine Service, at jeanne.hendrickson@yale.edu.

ICD-10 update

Although the Senate voted to approve a bill that will delay the implementation of ICD-10 by at least a year, Yale New Haven Health System will continue to move forward with ICD-10 implementation.

Yale-New Haven Hospital is continuing to make the transition from the old ICD-9 coding system to the new ICD-10 system. YNHHS is planning a clinical "go-live" on May 17, 2014 to allow providers and coders sufficient time to get acclimated to the new requirements. CPT coding and billing are not impacted by this conversion.

Education of providers on the new documentation requirements will be available in a number of formats, including:

  • Healthstream online modules: Mandatory one-hour training for all YNHH-employed providers between April 1 and May 17. Further information will be sent to you directly if you are an employed physician.
  • In-person tutorials: Brief clinician-led tutorials for groups most impacted by ICD-10 to review key documentation changes for a given specialty; completed during time already dedicated to local group/departmental meetings between now and May 17.
  • Webinars: A series of specialty-specific webinars for providers in the community and in ambulatory practices will be conducted during early evening hours between April 15 and May 17 and will be accessible on the new ICD-10 portal for reference after they have aired.
  • Online portal: A new online portal will serve as a reference library for a variety of user-friendly specialty-specific content and webinar access.
  • Discussion of Epic impact: Epic workflow will be minimally impacted by ICD-10 changes but some new Epic tools will be available to more easily assign new codes. We will distribute a link to a brief video that details what will change on May 17.

Our goal is to provide clinicians with the most streamlined, relevant education. We will continue to have resources available after May 17 for any questions that arise post our go-live date. If there are any questions about ICD-10 or upcoming training, please contact Dr. Ian Schwartz, MD, at ian.schwartz@ynhh.org.

YNHH Blood Bank to change plasma used in emergency situations

Given supply and demand issues, group AB plasma will now be reserved for patients with a known blood type of group AB. In emergency situations, group A plasma will be released for patients without a known blood type (Zielinski MD et al, J Trauma Acute Care Surgery, 2013). Any questions can be directed to Melanie Champion, Blood Bank manager, at melanie. champion@ynhh.org, or Ed Snyder, MD, Blood Bank medical director, at edward.snyder@yale.edu.

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