1. The difference between an EHR and an EMR?  Last month, the Office of the national Coordinator for Health Information Technology (ONC) released a report defining the EHR as a patient-focused record while the EMR is a record set up by and for a particular health organization.  An EHR has interoperability - the ability to exchange information among and across many healthcare systems  while an EMR is designed to simply replace a paper medical record in the hospital and generally lacks interoperability.   Electronic medical records that cannot exchange information will eventually loose relevance and become obsolte over time.


2. Third party denial information is still illusive in many hospitals. But with the right tools and processes a denial information system is possible.  Investing in technology to support this function is no longer optional - it is a critical component of every hospital financial system because unlike so many other initiatives, the benefits of denial reporting programs are real and tangible including enhanced cash flow, reduced rework, decreased cost-to-collect, and more effective contract negotiations. It's that old cliche, 'if you can't monitor it, you can't manage it.'  With access to the facts of payer denials, front-line case managers are better able to prevent them in the first place!


3. Under the 9th SoW, which goes into effect 8/1/08, the QIOs will be required to conduct 85% of their work in certain hospitals being targeted as in need of improvement in their surgical-care measurements. The list of targeted facilities can be found at   http://www.cms.hhs.gov/QualityImprovementOrgs/downloads/HospitalChart.pdf


4. Internal hand-offs between and among case managers, hospitalists, medical residents and nurses continue to present challenges and the few studies that have researched the problems have all found that the process is "variable, unstructured, and prone to error."  According to one study, 26 interns caring for 82 patients reported 25 discrete incidents that led to repeat or unnecessary tests. We have found that standardization of the hand-off process works.  Even a simple written form or computer template can go a long way in making sure that critical information such as code status, outstanding diagnostics or active and anticipated medical problem is not left out. Requiring that handoffs and signouts include a face-to-face conversation takes the process a step farther because even the most experienced provider can fail to adequately communicate the unpredictable nature of hosptial care. 

(This article is presented with the permission of its author Ronald Hirsch, MD.  It was written for the Sherman Hospital Case Management newsletter and intended for its medical staff. 



Has this ever happened to you? You are just about to leave the exam room at the office after a long visit with a patient. You have adjusted some medications, counseled about their disease process and ordered lab tests. As you walk out, the patient says, “By the way, doc, I have been having trouble with my knee for the last 6 months. Can you take a look?” You know that addressing this could take another 10 minutes so you ask the patient to schedule another appointment.

In the hospital the same thing happens but with the tables turned- you admit a patient for an acute illness and “while they are here” you order an evaluation for another unrelated stable problem.

Here’s an example of a patient from May. An 80 year old female was admitted for exacerbation of COPD. She received excellent care from her physicians and improved. But it was noted that she was mildly anemic on admission with a Hb of 10.6. GI was consulted and thought it may be dilutional but continued to follow. In Cerner it was noted that in January her Hb was 10.4. After 8 days, her respiratory condition stabilized and GI wrote for the colonoscopy prep. But it was Friday before a holiday weekend so she sat for 3 days. Then the first prep was inadequate so it was repeated that evening for another scope the next day. An adenoma was found, iron ordered and she was discharged.

The hospital charges for this patient will be submitted with the DRG for respiratory system diagnosis. In the five days she waited for her colonoscopy, she incurred over $25,000 in charges with no change in her DRG payment to the hospital.

Since her respiratory status was stable, if the Medicare Peer Review Organization (PRO) were to review this chart, they most likely would deny the physician charges submitted for those days.

So as you treat your hospitalized patients, be sure that you are providing care in the proper setting.

In 1967, Jack Wennberg, a young medical researcher at Johns Hopkins moved his family to Vermont to run a new program at the University of Vermont examining medical care in the state.  He traveled the state, collected data on procedures and came up with an odd finding: Medical practice across the state varied enormously.  In Middlebury, for instance, only 7% of children had their tonsils removed but in Morrisville, 70% did.  More research and more data collection followed to see whether different patterns of illness could explain the variations in medical care.  They couldn't. The children in Morrisville weren't suffering from an epidemic of tonsillitis. Instead they happened to live in a place where a small group of doctors had decided to be aggressive about removing tonsils.  The stunner however, was that Vermonters who lived in towns with physicians who treated aggressively were not healthier than other Vermonters - they were just getting more medical care. Dr. Wennberg eventually moved to Dartmouth where he and his colleagues have conducted versions of this original study again and again and come up with the same result.  Their well-respected research is published periodically in the Dartmouth Atlas and demonstrates time and again that the US spends more money on healthcare per person than any other country, but we are not healthier. 



This anecdote, which we first encountered in Michael Millenson's great book Demanding Medical Excellence, is now the backbone of another great book Overtreated:  Why Too Much Medicine Is Making Us Sicker and Poorer by Shannon Brownlee, a senior fellow at the New America Foundation and former writer for US News & World Report.  The book paints a clear description of the dynamics of the healthcare economy and is filled with information on care that brings no health benefit and worst of all, often causes harm.  We just finished reading it and recommend it for your library, or even better, as a gift for your favorite doctor! 

Successful hospital case management programs achieve and sustain their value position by delivering 'extraordinary levels of distinctive value' to carefully selected customer groups every day.  That's how Tricia Howard describes the success of her program in Jacksonville, FL.  "To be successful," Tricia wrote us, "we had to have a strong focus and be able to distinguish ourselves from our competitors down the road."

Tricia cites three distinct principles she uses in her program:

1.  Operational excellence.  Tricia reports that under the old UR/DCP model, her team tried to be all things to all patients and all physicians and it was impossible.  "I had a high staff turnover as they tried to do all the stuff that the exec team thought we should be doing."  Tricia developed a business plan with a consistent range of services to a selected population that was agreed upon the the C-suite and reports that she hasn't had a vacancy in 3 years. "It was important that we practiced consistently so that our customers didn't get confused.  We asked the same or similar questions, we queried the same practice and process issues, and we used the same resources to resolve cost and quality issues."   

2.  Customer intimacy.  When Tricia was recruited to the Director role, the staff were managing medical charts.  "We did a mini engineering study and found that 74% of the case managers' time was spent reviewing medical records." That left little time to work with the physicians, patients, and nurses.  In the business plan she developed, she envisioned a close working partnership with selected physicians, their patients and respective nurses.  "In the first year of our new model, the nurses were most challenging.  They were used to the case managers being on the units all the time and often used them to augment their practice.  When the case managers disappeared, the nurses reacted and we had to deal with a lot of negative publicity for nearly three months until the physicians saw the benefits of the new model and served as our champions."  In addition, because the new model provided case management serrvices to only selected populations, the nurses had to adjust to managing their patients from entry to exit, "something they weren't used to doing under the old model" says Tricia.

3.  Program Innovation.  The case management team now performs in harmony but they are constantly on the look-out for new ideas and new ways to meet organizational expectations.  Tricia said that "The team is now pretty self-sufficient and look to me to bring their suggestions and recommendations for improvement to the leadership group." For example, the team recommended incorporating a portion of the quality review positions into the resource center positions to reduce redundant chart review activities. Not only was this a cost saving measure, but the information obtained on a concurrent basis was shared with the case managers to immediately bring to the physician's attention.  

With Thanks to Tricia Howard for allowing us to share her email.    

A few years ago we encountered a hospital that assigned a seasoned nurse on a rotating basis to the emergency department to jump-start the initial patient assessment.  It seemed like a creative idea to provide senior clinical nurses an opportunity to experience a new environment, to learn first-hand the importance of an accurate and complete assessment, to gain exposure to the challenges of moving patients through a busy ED and to participate in the gatekeeping functions. On the other hand, there are probably as many detractors to this idea as there are proponents.  

Now comes a similar practice that is beginning to surface among hospitalist groups: Rotating hospitalists into the ED to serve as the admitting physician. This practice too, which we are just starting to encounter, has its supporters and detractors.  On the plus side it would certainly cut down on the number of interruptions that hospitalists encounter during inpatient rounds.  It also would keep the hospitalist's focus on both the clinical and business considerations that constitute the gatekeeping function. The consistent presence of an admitting hospitalist makes it easier for the EDCM to 'educate, inform,and counsel' on many of the business issues that often impact level of care decisions for both the patient and the physician. And finally,it would enable the rounding hospitalists to devote their full attention to their patients.

On the other hand, it increases the number of 'hand-offs' that we know to be a source of many hospital errors and due to the unpredictability of inpatient census or admission volume, especially in smaller hospitals, it may create an unequal distribution of work responsibilities. 

The verdict is still out whether this practice will gain popularity. We can envision that the model would be very popular in hospitals with busy inpatient and ED admission volumes. If an ED is admitting between 30 - 60 patients a day, having a dedicated admitting physician might very well be worth it.   

The role of the emergency department case manager [EDCM] is among the most frequent questions we receive via your emails.  At your request, we are pleased to clarify our encounters with successful ED case management programs.  Successful ED case management programs function primarily as gatekeepers for the facility.  The principle is based on the fact that every patient who walks into the ED does not require an inpatient admission to treat his or her immediate needs.  The EDCM provides supplemental information to the clinical team prior to beginning the admission process to ensure that the patients' needs can only be met at the acute level of care. Objective information must support that determination because without it, the hospital and perhaps the patient, are put at risk.  The EDCM is best prepared and positioned to provide information about the correct billing status (inpatient or outpatient/observation) and can collaborate with the bed management team (or whoever is responsible for elective or direct admissions) to identify opportunities to avoid using inpatient days for services that can be more safely and cost-effectively provided on an outpatient basis.

The EDSW on the other hand, generally works with ED patients who present with social or educational needs. These complex populations are often the cause of ED backup and make up the largest segment of return visits.  The EDSW can facilitate creative transportation, make referrals to community social services, find follow-up medical or dental care for unfunded patients, locate safe havens for victims of domestic violence, and assist patients with innovative solutions to obtain clothing, food, medications and equipment.   "Social admissions" of elderly patients who can no longer care for themselves at home and have no acute medical needs can be significantly reduced through the efforts of the EDSW.

The dyad model of hospital case management - typically, a case manager partnered with a social worker - is a costly approach and we do not routinely find it in community hospitals. However, the combination of an EDSW and an EDCM dedicated to the emergency department is an asset worthy of investment by every hospital no matter what the size. 

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a valuable resource containing hospital-specific Medicare claims data statistics for target areas that have been identified by the CMS as high risk for payment errors. These target areas include one-day stays, hospital readmissions and several DRGs that have historically been associated with payment errors.

PEPPER uses hospital-specific percentiles for each target area to determine "outlier values" typically reported as exceeding the 10% The outlier values reveal how unusual a hospital's findings are, relative to other hospitals in the state. Positive outlier values indicate possible overcoding or questionable medical necessity of admission, and negative outlier values indicate possible undercoding.

PEPPER helps hospitals identify areas in which there may be opportunities for compliance improvement.  Over the last few years, we have found that only a smattering of program Directors know the existance of PEPPER and even fewer with whom the reports are shared.  Do yourselves a favor....ask about PEPPER in your hospital.  Ask to see a copy of the report.  If you are using a physician-centric model, PEPPER information can be very valuable in terms of helping a physician stay 'under the radar' by documenting more accurately.  If you are using a 'targeted' model (see article below), PEPPER can assist in identifying high risk diagnoses and if you have a robust EDCM program, level of care discrepancies would be good information to strengthen gatekeeping initiatives. 

• From Margaret Freundl in Warren, MI - Contracting with an external physician advisor to support gatekeeping activities. The physician augments the work of the EDCM to ensure qualified admissions. Patients in the ED as well as direct admits from the physician offices are often referred to the physician advisor when differences surface. Due to compliance issues, they began by focusing on Medicare patients but are now ready to take the next step and focus on all admissions.
• From Sue Barlow, Warrensburg, IL - Our best idea was the creation of a centralized Support Station to handle all the clerical and chart review activities that we've had to do since the inception of our program in  1999. "This has freed up the case managers so we can now show how we have reduced costs and generated revenue for the hospital". Sue reports that each case manager just got personal Blackberries as a thank-you gift from their CFO.
• From Barb Dalenberg, IL - The community has a large self-pay population who often present themselves to the ED. Barb reports that they recruited a retired Public Aid counselor who now works as an EDCM and targets every self-pay patient to begin the process of applying for public assistance. "These are patients we would probably have missed," Barb reports.
• Sharon Dimit, West Valley City, UT reports that putting an EDCM in place is the best idea they had to improve their gatekeeping responsibilities. They are now shifting some resources within the program to cover the ED on a 24/7 basis.
• Dot Perez reports that "saturating the medical staff with information as well as quarterly report cards" have been effective strategies to get physician buy-in to the case management program at her facility.
• Crystal Redding of Winston-Salem NC boasts that the data she captured and quantified concerning non-qualified and social admissions through the ED led directly to the organization's investment in EDCM and EDSW FTEs. They continue to capture data and turn it into information to demonstrate how case management interventions in the ED has improved ED capacity and patient flow.

Source: With many liberties from Glaser and Garets, Healthcare Informatics, 2/06