PookieMD's Blog: Where Physicians Learn About the Business of Medicine

In the last two weeks I have spent time at two completely different hospital system, and by default, spent a lot of time in their EDs.  One ED is efficient, the other over orders and under delivers, and easily becomes overwhelmed.  So what is the difference?

First, the two EDs serve two very different populations.  One is the go to hospital for a large HMO in the area.  The other is a large, urban trauma center, serving a significant population of the homeless as well as weekend warriors that are getting fancy hip replacements.  Guess which one is more efficient and effective?

If you guessed the HMO hospital, you guessed wrong.  The large sprawling hospital with “we take ‘em all” attitude is more efficient at healing and dealing with patients.  They don’t have a fancy EMR, they don’t have smarter docs, or better nurses, or fancier equipment.  (It’s actually kind of an arm pit of an ED.)  What they have is a culture where patients are fully worked up and all avenues are explored before a patient is admitted.  Let’s call this ED “A” (for armpit!) and the second ED at the fancy HMO ED “F” (for fancy.)

Differences:

ED A values disposition, looking at hospital admission as a last option.  This is based on the fact that with such a significant homeless population, hospital A would go out of business if ED A admitted everything. 

ED F, on the other hand, values through put.  ED F will get paid on every patient they see, and the hospital will get paid by the HMO for every patient that is admitted.  There is no incentive to not admit patients.  Rather, there is incentive to clear the decks of the ED and move patients through to the hospital.

ED A must complete work ups so they can dispo patients effectively.  ED F frequently will call and say, “Mr. Oldtimer can’t walk, and I don’t know why, so he needs to come in.”  Work ups stop as soon as patient is admitted because, for ED F, it is easier just to admit patients than work them up and attempt a disposition.

Hospital A has a powerful hospitalist group that has a lot of clout.  The hospitalist group and hospital don’t want to admit patients for social reasons.  Again, finances play a large part in this culture of disposition.  Hospital F has a hospitalist group that has no clout, and is viewed as a baby sitting service by the ED.  ED A will hear about it from the hospitalist group if work ups are incomplete.  ED F will hear nothing.

So, if you are looking for an efficient, effective ED group, don’t look at the fancy ED with the fancy EMR and state of the art equipment.  Look at the ED group who understands that a hospital is not a hotel, and that it is for sick people only.  This is how to save health care dollars!

My husband, born with hip dysplasia, got a hip replacement this past week.  He’s young, (under 50) and the surgery went relatively well.  What was fascinating was how the orthopedic surgeons ran their practice.   It was striking how different it was from the management of a medical practice.

At Hubby’s initial consultation, the orthopedic surgeon met my husband, while his assistant recorded the encounter.  The physician never touched paper or computer; the assistant did it all.  After getting x-rays, Hubby received a DVD to watch at home, explaining the procedure.

After that, the scheduler set up the surgery.  Then Hubby attended “Hip Class” at the hospital where the PA, the physical therapist and the liaison RN reviewed what to expect at the hospital, during the operation, and in the post op period.   The class toured the hospital, got their blood drawn, and then went home with a notebook containing information on every aspect of the procedure, from pre-op to the rehab period.  The ten chapter book contained sections on lovenox dosing, therapy exercises, and contact numbers.

Before surgery, the practice’s pharmacist called to review my husband’s medications (none) and discuss lovenox dosing (again.)  The lovenox arrived in the mail, before he ever went to surgery.

In the hospital, my husband was seen daily by a PA, practice RN, and hospitalist.  The orthopod never visited Hubby following the surgery, and won’t until his follow up visit at the office.

What if internal medicine was like this?  What if a patient with pneumonia received a DVD and book about causes, treatment and expectations of patients with pneumonia, a pharmacist call and a nurse liaison and a PA through every step of the hospitalization? What would the outcomes be like?  (However, I do think medicine patients need a daily visit from a hospitalist!)

It is interesting, that my husband, a healthy male, received much more attention and follow up than an 80 year old with pneumonia, COPD and a NQWMI.  My husband’s comment was that it was relatively impersonal, but my response was, “well, how does an 80 year old feel that meets me for the first time in the ED, and spends 4 days with me when they are critically ill?  How personal is that?”

I think that the reason so many resources were spent on my husband was due to the fact that the total fees generated by the surgery, before insurance discounts, will be in the range of $75,000.   A medicine patient will not generate nearly so much revenue for a three day stay.  We need to revamp our priorities, and realize that providing comprehensive care for the 80 year old will actually cost us less in the long run.

I do most of of my work in the hospital, and have tried to find ways to be more effective and efficient.  Premium is the time I spend with patients, so I try to be efficient with the paper work and phone calls to allow me to spend more time with patients.  Here I my top tips for making it through the day:

• Bundle your work.  When I go on to each floor, I get the charts I need, and prefill out the vital signs, labs, x-rays and assessments.  I check the MARS daily and note “medications reviewed.”  I also read other physicians notes so I fully apprised of other physicians’ plans.  I can always add to my assessment/problem list.  This allows me to go in to the patient’s room fully versed and ready for questions.  When I use an EMR, I prepopulate all my notes, and order medications and studies first thing to get them done faster.
• Tell patients when you will call their families.  Sometimes it’s more efficient to call families daily, as you end up spending less time in the end.  I make all phone calls in the afternoon when I am finished rounding.
• Never schedule family meetings in the morning, if possible.  I schedule them for the afternoon, again, hopefully when I am done rounding.  I believe that I owe it to my other patients to have seen all of them before I spend time in an extended family meeting.  I know this is not always possible, but I try to mindful that I have at least 15 other patients that need care as well.
• Write legibly.  Avoid pages by ward secretaries asking if you wanted lantus or lanoxin.
• Consider giving your pager number to families.  This can avoid endless telephone tag, and I have NEVER had a family abuse this.
• Learn every EMR short cut you can.  I use EPIC and Meditech, and am still learning all the bells and whistles.
• Call specialists early in the day.   One of the benefits of pre populating notes is that you can see problems early, and call specialists in sooner vs. later, resulting in better patient care.
• Make sure you have answered and addressed ALL your patients’ and families’ concerns before leaving the room.  Before exiting, ask if anyone has any other concerns or questions that need to be addressed.  Avoid complicated explanations.  Yes, you will still get pages from nurses asking you to come explain (again!) to the family why Grandpa needs antibiotics for his pneumonia but you will cut down on these calls.
• Use a check list.  When I am rounding, I have a paper list of my patients.  I have several columns that I check off as I see each patients.  These columns are headed as follows: meds (I check this off when I have reviewed their medications), labs (checked when labs are ordered for next day), x rays (checked off if I have ordered studies),  and note (when  note is completed.)  I also put here anything I want to follow up on.
• Communicate with nurses effectively.  When they call you, make sure you know what they want, and insist on read backs on all verbal orders.  If you are changing the treatment plan,tell the nurse!  They are your front line on getting things done, and can make the wheels turn.

Good luck out there!  One of my friends (an ID doc) asked if being a hospitalist was like being an intern.  Some days it feels like that, but other days it’s like butter!

What tips do you have?