Inpatient Practice Medical Economics

The 5 Faces Of Value In Medicine

In medicine, we talk about quality a lot. But most of the time that we are talking about it, we’re really not talking about quality at all. You see, quality means different things to different people and most of the time, we are confusing quality with value.

Value = Quality ÷ Cost

There are 5 faces to quality value:

  1. The physician. When you ask a doctor what quality is in medicine, he/she will tell you that it is getting the right diagnosis, prescribing the right treatment, and doing it in a timely fashion without complications occuring. In other words, quality to the doctor is doing the standard of care in medical practice.
  2. The patient. To understand what quality means to the patient, all you have to do is look at the questions in the CG-CAHPS survey. There are no questions about correct diagnosis or correct treatment. The questions are all about timeliness of the office visit, whether your questions were answered, and whether you were treated nicely. Because that is what is important to the patient: whether they could get an appointment to see the doctor when they wanted to, whether they had to sit in the waiting room too long, whether they get test results back quickly, and whether everyone in the office is friendly. Most of the time, the patient doesn’t know whether or not the doctor nailed the diagnosis or prescribed the proper medication so they judge the doctor on the service that they received. As physicians, we usually know who the good doctors are and who the bad doctors are – and then it surprises us when the bad doctors are rated higher than the good doctors in patient ratings and reviews. That is because what constitute “good” and “bad” in a doctor means totally different things to patients as opposed to physicians.
  3. The hospital. Every hospital has a quality department and that department will regularly report quality metrics. But many of these metrics are not really quality metrics, they are value metrics. For example, length of hospital stay, cost per adjusted admission, and emergency department throughput times are reported on just about every hospital quality scorecard in America but these don’t really translate into whether the patient’s disease was diagnosed and treated correctly, they are more directed toward the financial viability of hospital operations. If you examine the HCAHPS survey, then once again, you can get a pretty good idea about how hospital quality is judged: Was it clean? Was it quiet? Did the hospital personnel treat you nicely? Was your pain attended to? There is nothing in the HCAHPS survey about whether your condition was diagnosed correctly and whether the right surgery was performed or right treatment was prescribed.
  4. The insurance company. I periodically get quality scorecards sent to me from insurance companies that rate me on various metrics that the insurance company considers important. But they are usually dominated by whether or not the level of service charges that I bill are out of line with other pulmonary and critical care physicians. In the value equation, the most important component to the insurance company is cost – whether the doctor is charging too much, whether the doctor orders too many expensive CT scans or MRIs, and whether the medications that the doctor prescribes are the least expensive on the insurance company’s medication formulary. Furthermore, the insurance company is focused on the prevention and effective treatment of those diseases that will affect the patient during the time the insurance company is covering that patient and not with diseases (such as hepatitis C) that will not affect the patient until after they turn 65 and go off of the insurance company’s policy and onto Medicare.
  5. The employer. In the United States, it is ultimately the employer who pays for most medical care for Americans under age 65. That is because the employer hires the health insurance company to determine which doctors and hospitals to send the employees to and how much to pay those doctors and hospitals. To the employer, quality in medicine means keeping the employee in the workplace as much as possible. That means that the employer values physician evening and weekend office hours so the employee doesn’t have to take time off work for regular visits. It means preventing common illnesses such as influenza so that the employee doesn’t have to take time off work being sick. And it means keeping the employee’s children healthy so the employee does not need to stay home with a sick kid.

So, which of these five faces of quality is correct? The answer: they all are. And we in medical leadership roles need to recognize that quality means different things to different groups and for us to practice high quality medicine, we have to think outside of just what quality means to doctors.

March 30, 2018

Inpatient Practice

Deciphering The Medicare Hospital Star Rating System

CMS just released its newest star ratings for U.S. hospitals. The ratings were supposed to come out last summer but there was a delay because of problems with the methodology Medicare was using. The rating system attempts to compare hospitals’ performance with common conditions. Hospitals are rated with 1 – 5 stars, with 5 stars being the best and 3 stars being average.

Medicare uses a 6-step process for calculation of the number of stars awarded to each hospital:

Step 1: Selection and standardization of measures for inclusion in the Star Rating 

Step 2: Assignment of measures to groups 

Step 3: Calculation of latent variable model group scores 

Step 4: Calculation of hospital summary scores as a weighted average of group scores 

Step 5: Application of minimum thresholds for receiving a star rating 

Step 6: Application of clustering algorithm to categorize summary scores into star ratings

Medicare evaluates hospitals on up to 57 different measures. Not all hospitals have sufficient volumes of patients for each measure so the average hospital is rated on about 39 different measures. The measures can be grouped into seven different categories and then each category has several different measures:

  1. Mortality (7 measures)
    1. Death rate from heart attack
    2. Death rate from CABG
    3. Death rate from COPD
    4. Death rate for CHF
    5. Death rate for pneumonia
    6. Death rate for Stroke
    7. Death rate for patients with serious complications from surgery
  2. Safety of care (8 measures)
    1. Central line-associated bloodstream infections
    2. Catheter-associated urinary tract infections
    3. Surgical site infections from colon surgery
    4. Surgical site infections from abdominal hystectomy
    5. MRSA
    6. Clostridium difficile infections
    7. Knee/hip replacement complications
    8. Serious complications
  3. Readmission (9 measures)
    1. Heart attack
    2. CABG
    3. COPD
    4. Heart failure
    5. Knee/hip surgery
    6. Pneumonia
    7. Stroke
    8. All discharged patients
    9. Unplanned hospital visits after outpatient colonoscopy
  4. Patient experience (11 measures)
    1. Nurse communication
    2. Doctor communication
    3. Patients reporting receiving help as soon as they wanted it
    4. Pain control
    5. Patients reporting that staff explained about medications before giving it to them
    6. Room and bathroom cleanliness
    7. Hospital room was quiet at night
    8. Patients reporting that they were given information about what to do during their recovery at home
    9. Patients reporting that they understood their care when they left the hospital
    10. Overall patient rating of the hospital
    11. Patients reporting that they would recommend the hospital to a friend or family
  5. Effectiveness of care (10 measures)
    1. Patients getting flu shots
    2. Healthcare workers getting flu shots
    3. Aspirin within 24 hours of arrival with chest pain or heart attack
    4. Patients leaving the ER without being seen
    5. Patients with stroke symptoms who got a CT within 45 minutes of arrival
    6. Percentage of patients receiving appropriate recommendations for follow-up screening colonoscopy
    7. Percentage of patients with history of colon polyps getting follow-up colonoscopy in appropriate timeframe
    8. Percent of mothers whose deliveries were scheduled 1-2 weeks too early
    9. Patients who developed a blood clot and did not get DVT prophylaxis
    10. Percentage of patients receiving appropriate radiation therapy for cancer that spread to the bone
  6. Timeliness of care (7 measures)
    1. Time waiting in the ER for patients admitted to the hospital
    2. Time spent in the ER after the doctor decided to admit the patient to the hospital
    3. Minutes before patients with heart attack needing specialized care were transferred to another hospital
    4. Minutes from presentation to the ER to getting an EKG for patient with possible heart attack
    5. Total time in the ER for patients released (without admission)
    6. Time spent in the ER waiting to be seen by a healthcare professional
    7. Time waiting in the ER before getting pain medication for patients with broken bones
  7. Efficient use of medical imaging (5 measures)
    1. Outpatients with low back pain getting an MRI without getting physical therapy first
    2. Outpatient CT scans of the abdomen that were combination scans
    3. Outpatient CT scans of the chest that were combination scans
    4. Outpatients getting cardiac stress tests before low-risk outpatient surgery
    5. Outpatients with brain CT scans go also got a sinus CT at the same time

The different categories are weighted differently in the final calculation: the first four categories are weighted 22% each and the last three categories are weighted 4% each. Therefore, they way to have your hospital perform well on the star system is to have a low mortality rate, have a low readmission rate, have a low incidence of hospital-acquired conditions, and have happy patients. The selection of the various measures within each of these categories becomes extremely important since different hospitals inevitably do better at some things than at others. Also, the time period that the measures are collected over varies with some measures collected from 2013-2016, others from 2015-2016, and still others from 2016-2017. The 57 measures can be found on the CMS Hospital Compare website. Some of these measures are rather general (e.g. percentage of patients who reported that their doctors communicated well) and others are rather specific (e.g. surgical site infections from abdominal hysterectomy). Some of the measures are directed toward patients (e.g. the percentage of patients assessed and given influenza vaccine) and some are directed toward the hospital employees (e.g. the percentage of healthcare workers assessed and given influenza vaccine).

Here is the overall star ratings for U.S. hospitals for 2016 and 2017. Notably, the percentage of both 5-star and 1-star hospitals increased since 2016.

The measures that CMS chooses end up being the “invisible hand” that dictates hospital priorities. Every year, hospital quality departments analyze whichever measures CMS has most recently chosen and hospitals focus on trying to do their best to keep the numbers up for those specific measures. Thus the CMS star system directs how hospitals will use their limited resources to improve their performance on those specific measures. This results in Medicare having a huge impact on how hospitals define quality and how they elect to improve quality outcomes. One of the challenges that hospitals face is that the measures look backwards for up to 3 years and the specific measures change from year to year so you never know exactly what you are going to be judged on from one year to the next and the data usually reflect your performance from more than a year ago.

So, does the CMS Hospital Compare star rating system really tell you which hospital in your area is the best one? Well… maybe. If you are being admitted for an elective hip replacement surgery, it probably doesn’t really matter to you how many minutes patients in the hospital’s emergency room spend before being discharged. But if the hospital performs well on the star system, then this indicates that the hospital is at least monitoring quality metrics and working to try to improve those metrics. So, if you are being admitted with gastroenteritis, then hopefully the things that the hospital is doing to reduce heart failure mortality will also spill over to keep gastroenteritis mortality down, also.

This year, our medical center did very well and got a 5-star rating and we are very proud of that accomplishment. I’d like to think that is because we provide the highest quality care possible but the reality is that a lot of hospitals that I know got 2, 3 or 4 star ratings even though they are very good hospitals that I would be comfortable being treated at. The star rating system is imperfect but consider it as a work in progress that is a first start at trying to objectively quantify medical quality.

January 18, 2018

Inpatient Practice Medical Economics

Inpatient Palliative Medicine Services: Making The Right Economic Projections

The demand for inpatient palliative medicine services is very high and the supply of palliative medicine physicians is rather low. When considering bringing palliative medicine services to your hospital, the real value of palliative medicine is in what does not appear on the basic accounting pro forma. A robust palliative medicine service is a multidisciplinary team composed of a variable group of individuals that may include: physicians, nurse practitioners (or physician assistants), social workers, pharmacists, psychologists, and clergy. Palliative medicine is expensive and virtually all palliative medicine services will require some subsidy by the hospital since it is exceedingly difficult to pay for palliative medicine from professional billing alone. Here are some of the factors to consider when contemplating bringing palliative medicine to your hospital.

Estimate the clinical volume.

A commonly quoted figure is that 5% of the hospital census will use palliative medicine services (excluding maternity and psychiatry patients) and some literature supports up to 20% of inpatients will utilized palliative medicine. However, there is danger is just using a flat percentage of the hospital census. For example, patients in observation status rarely require palliative medicine. These are patients who are technically outpatients but who spend 1-2 days in the hospital, often for evaluation of symptoms such as chest pain, syncope, or vomiting.  Although many times these patients may have underlying diagnoses that warrant care by a palliative medicine specialist, this care is often better provided in an outpatient office setting due to their short stay in the hospital. Therefore, a hospital that has a high percentage of observation status patients will have less overall utilization of inpatient palliative medicine services.

One way of estimating the demand for palliative medicine consultation is to survey your inpatient services. The best way to do this is to take a “snapshot” of the demand on any particular day. To do this, pick a typical day and contact each hospitalist and admitting physician on that day to ask: “Hypothetically, if there was palliative medicine consultation today, how many of your patients would warrant palliative medicine services?”. Then check to see what each of these physicians’ hospital census is at that moment. In a typical community hospital, most of the patients who would warrant palliative medicine services will be medical (as opposed to surgical) patients. In a tertiary care hospital that has a lot of subspecialty surgical services (such as burn, trauma, surgical oncology, or thoracic surgery), this may be different. Next, take the total number of patients who would warrant palliative medicine services on that particular survey day and divide by the average length of stay – most hospitals will track medical and surgical patient length of stay separately so if all/most of the patients who are identified as potentially benefiting by palliative medicine are medical patients, then use the medical patient length of stay. This will give you the average number of new palliative medicine consults per day that you can expect. If you anticipate that you will only have routine palliative medicine consultation on weekdays, then multiple your number by 1.4 to estimate the number of new consults per day given a 5 weekday work week.

Estimating the number of inpatient return visits (after an initial palliative medicine consult) is tricky. On the surface, you could use your average hospital length of stay and assume that the palliative medicine consult is done on day one and then the palliative medicine service sees that patient every day for the rest of the hospital stay – so if your average length of stay is 4 days, then the number of return visits would be 4 -1 or 3. There are a couple of problems with this analysis, however. (1) Palliative medicine consultation may not be done on day #1 either because the need for palliative medicine services is not clear on the first hospital day or because the first hospital day falls on a weekend when palliative medicine services may not be available. Also, if a patient is admitted at 6:00 PM, then the initial palliative consult will not be done until the following day (second hospital day). (2) The palliative medicine service may not need to see the patient every day of the patient’s hospital stay (for example, when waiting for a critical test result, waiting for family members from out of town to arrive for end-of-life discussions, or weekends when palliative services may not be as regularly available). (3) The hospital average length of stay can be misleading since patients requiring palliative medicine services tend to have a higher length of stay than the average hospital patient. If you are unsure, then estimate 4 return visits for every 1 new consult.

The disease mix of the hospital will also impact the utilization of palliative medicine services. The big three are cancer, congestive heart failure, and COPD. So, even if there is a big cancer hospital in your community where most of the cancer patients go, you will still have a lot of need for palliative care if you have a high percentage of COPD and heart failure admissions.

Estimate The Professional Revenue

Ever since Medicare eliminated consultation codes a few years ago, all consultants now have to bill an inpatient new visit (CPT 99221, 99222, or 99223) rather than a consult code. Most initial palliative medicine visits will be 99223, for which Medicare pays $200 (99222 pays $136). CPT 99223 consists of 5.73 total RVUs (3.86 work RVUs, 1.58 expense RVUs, and 0.29 malpractice RVUs).  Therefore, the amount of money to go toward a physician’s salary from a new patient level 3 visit is about $135 (3.86 wRVUs x $35/RVU Medicare conversion rate). Lets say you do your survey of the need for palliative medicine services and you determine that working Monday through Friday, there would be an average of 3.8 palliative medicine consults per weekday and lets further assume that the palliative medicine physician works 46 weeks a year (assumes 3 weeks of vacation, a week of CME, and 2 weeks of holidays per year). That means that the palliative medicine physician will generate $118,000 toward salary + benefits from initial consults alone.

Next assume that there are 4 follow-up visits for every initial consult and assume an even mix of level 2 (99232) and level 3 (99233) return hospital visits. Using the same analysis as above, a level 2 return visit will generate 1.39 wRVUs ($49) and a level 3 return visit will generate 2.00 wRVUs ($70). Therefore, the palliative medicine physician would be expected to generate $55,000 per year toward salary + benefits from return visits.

By combining the projected new patient consults plus return visits, in this example, you come up with the palliative medicine physician being able to generate $173,000 toward salary plus benefits. Assuming a 25% benefit rate, that works out to generating $138,000 toward salary. Further assuming a $230,000 salary for a palliative medicine physician, this works out to the physician being about to generate about 60% or his/her salary by professional billing.

Should Palliative Medicine Physicians Bill Time-Based CPT Codes?

But what about time-based billing? Frequently, palliative medicine physicians spend an enormous amount of time for each visit, particularly when discussing end-of-life care or withdrawal of life support in the ICU. In these situations, it can be advantageous to bill “prolonged service” CPT codes in order to get paid for time rather than purely being paid a conventional level of inpatient service. The prolonged service CPT code 99356 (first 30 minutes to 60 minutes of prolonged services) generated 1.71 wRVUs ($60) and the prolonged service CPT code 99357 (each additional 15-30 minutes of prolonged services) also generates 1.71 wRVUs ($60). To bill prolonged services, the physician must first meet the time threshold for a regular new patient or return patient visit CPT code and then a minimum of an additional 30 minutes (99356) or 75 minutes (99356 + 99357). From the table, you can see the total thresholds that Medicare uses for prolonged service billing and that physician’s actual time has to be documented in the physician’s progress note in the patient’s chart. Using the prolonged service charges helps recoup the cost of the palliative medicine physician’s time when he/she needs to spend a lot of time counseling the patient and their family. But you really can’t make a living billing by time. If you calculate out the physician reimbursement on an hourly basis, then if a physician bills prolonged services, it works out to between $70 and $118 per hour from wRVUs. If you assume that the average palliative medicine physician spends 40 hours a week in patient care (leaving an additional 12 hours of a 52-hour work week doing non-reimbursable activities), works 46 weeks a year, makes $230,000 per year, and has an additional 25% benefit cost, then billing purely based on time, the palliative medicine physician can generate only about $139,000 per year toward his/her take home salary or about 60% of their income.

Either way you look at the professional billing in this model, the physician can generate about 60% of his/her income through billings (based on Medicare reimbursement levels). This means that a hospital is going to have to come up with about $115,000 subsidy per palliative medicine physician in order for the physician to have a competitive salary. In an academic medical center, it may take more than $115,000 per year after factoring in the addition costs of Dean’s tax, unfunded teaching/research, fellow’s salaries, etc.

Don’t Forget About The Intangible Benefits

After reading this analysis so far, you might wonder why any hospital would want to have palliative medicine? The physicians can’t cover their salary, they don’t bring any new admissions to your hospital, and they don’t bring in high value surgical cases. It may seem like all that they bring is additional costs. The real benefit of palliative care lies beneath the standard Profit and Loss Statement. The value of palliative medicine lies in the intangibles.

There is an abundant literature about the indirect cost benefits of palliative care. A meta-analysis of palliative care consultation in the ICU in the Journal of Intensive Care Medicine in 2016 showed that palliative care reduced the ICU length of stay and reduced the ICU costs by $1,100. A recent meta-analysis in the journal Palliative and Supportive Care showed that whereas there was a slight increase in total hospital length of stay by 0.19 days by bringing in a palliative care service, there was a 34% decrease in inpatient mortality. In a study of 2 academic medical centers published in the Journal of Palliative Medicine, the authors found that palliative medicine reduced hospital costs by $2,141 per patient for those patients with lengths of hospital stay < 7 days and by $2,870 per patient for those patients in the hospital for > 7 days. In a study from the Journal of Palliative Medicine from a single large urban academic medicine center, palliative medicine consultation in the hospital resulted in a reduction in 30-day readmission rate from 15.0% to 10.3%.

From these and other studies, we can make the following conclusions:

  1. Palliative medicine probably won’t improve your hospital’s overall length of stay
  2. Palliative medicine will improve the ICU length of stay
  3. Palliative medicine will reduce the inpatient mortality rate (by encouraging discharges to hospice when appropriate)
  4. Palliative medicine will reduce ICU costs
  5. Palliative medicine will reduce overall hospital costs per admission
  6. Palliative medicine will reduce 30-day readmission rates

The quality metrics of 30-day readmissions and inpatient mortality rates have minimal dollar costs to them but as publically-reported measures, these two metrics can have substantial public relations costs to them. On the other hand, because the ICU can often be a patient-flow bottleneck in many hospitals, there is a more direct financial benefit by reducing ICU length of stay in order to create additional ICU capacity.

Does Palliative Care Pay For Itself In Reduced Hospital Costs?

The real savings comes from reducing hospital costs per admission. By reducing ICU length of stay, the expense of the ICU’s higher nurse:patient staffing ratios, more intense use of respiratory therapists, use of mechanical ventilators, etc. can be reduced. Patients receiving palliative care can often have de-escalated care resulting in less frequent blood tests, lower use of antibiotics, discontinuation of chemotherapy medications, and reduced imaging tests. If you assume an average cost savings from the published literature of $2,500 per admission for those patients receiving palliative medicine consultation, then the hospital would need on an annual basis:

  1. 115 patients to cover the total cost of a palliative medicine physician (assuming that physician did no billing at all).
  2. 46 patients to cover the hospital’s subsidization cost per palliative medicine physician (assuming the physician bills for 40 hours a week of patient care).
  3. 50 patients to cover the cost of a nurse practitioner (assuming the NP does no additional billing)
  4. 28 patients to cover the cost of a social worker

Adding all of these together, to have a robust palliative medicine service with a physician, a nurse practitioner, and a social worker, the hospital would need to have 124 palliative medicine consults per year in order to break even.

Not all palliative medicine consults have equal economic benefit. Because of the high cost of the intensive care unit and long length of stay of patients requiring ICU care, palliative medicine consult to the ICU has the greatest financial benefit. Because ICU care can additionally be emotionally taxing for both patients and families, palliative medicine in the ICU can be particularly effective at improving patient comfort and satisfaction. Therefore, if there are only enough resources to provide limited palliative medicine consultation, start in the intensive care unit.

“Charge” Savings ≠ “Cost” Savings

There is a danger in preceding analysis, however. In many journal articles, investigators will report “costs” in the studies but what they really looked at was the patient charges in a hospital’s charge master. It is easy to figure out the patient charges but relatively hard to actually calculate the hospital’s true cost. For example, the hospital may charge $300 for a dose of an antibiotic but the true cost of the antibiotic medication is only $24; however, the charge will have to not just cover the actual purchase price of the drug but also the pharmacist’s time, the price to store the medications, the administrative cost of negotiating the purchase price from the manufacturer, the cost of the infusion pump to push the antibiotic through the patient’s veins, etc. The hospital also has to inflate the charges to make up for all of the uninsured patients or Medicaid patients that the hospital loses money on. Furthermore, the charges posted on the hospital’s charge master are only charged to uninsured patients – insurance companies individually negotiate what they will pay a particular hospital for any given service and the negotiated price is always less than the hospital’s charge listed on the charge master. Furthermore, Medicare will only pay the hospital the Medicare rate for any service, regardless of what the hospital charges for that service.

So, if we take a more conservative approach to interpreting the literature on cost savings by palliative medicine and assume that most of the time, when studies say costs but really mean charges, that the true financial benefit of palliative medicine is less than the benefit in charge reduction. Lets assume that a hospital has a gross collection rate of 40%, meaning that they get paid, on average, 40% of whatever charge is listed on their charge master. Then if the reduction in hospital’s charges is $2,500 per admission then the reduction in actual costs is about $1,000/admission. That changes the previous analysis so that the hospital would need on an annual basis:

  1. 287 patients to cover the total cost of a palliative medicine physician (assuming that physician did no billing at all).
  2. 115 patients to cover the hospital’s subsidization cost per palliative medicine physician (assuming the physician bills for 40 hours a week of patient care).
  3. 125 patients to cover the cost of a nurse practitioner (assuming the NP does no additional billing)
  4. 69 patients to cover the cost of a social worker

That robust palliative medicine service with a physician, nurse practitioner, and social worker would now need 309 palliative medicine consults per year in order to break even. The good news, is that 309 palliative medicine consults per year is a very low number and even a small hospital should be able to generate far more palliative medicine consults per year. For a very rough estimate, if your hospital has 2,500 medical admissions per year (not including observation status), then you will break even on your robust palliative medicine service.

Estimate Donor Potential

If you read the obituaries in your local newspaper, you’ll often find the sentence “In lieu of flowers, the family asks for donations to the Acme Hospice”. This isn’t surprising since the surviving family members see first-hand the enormous good that palliative care does. Furthermore, charitable donations are a little like a game of musical chairs, whoever is sitting in the chair when the music stops playing, wins – in this case, whichever charitable cause is with the patient when they die, wins.

So, when you set up a palliative medicine service, also set up a development fund where grateful families and friends can make tax-deductible donations in honor of those patients who benefitted by your hospital’s palliative medicine services. You can take about 5% out of a development fund per year and still keep that fund running in perpetuity without running out of money so once your palliative medicine fund reaches $2.25 million, you can cover the hospital’s subsidy costs to pay for your palliative medicine physician. Thus, a palliative medicine service is a long-term hospital investment: each year you have palliative care, your development donations add up and eventually your investment pays off.

The Bottom Line

The reason so many hospitals struggle with palliative medicine is that you cannot use the same type of pro forma that you would use for any other medical or surgical service. There is not much of a ramp-up period and it won’t bring you new business. The real benefit is improving the financial margin by cost reduction. Improved margin, better patient care, how can you lose?

December 27, 2017


Inpatient Practice Outpatient Practice

Should Your Hospital Hire Locum Tenens Physicians?

It is a vexing question that most hospitals and medical practices face eventually: when you have an expected or unexpected physician vacancy, do you bring in a temporary substitute? Locum tenens is a huge business – rarely a day goes by that I don’t get a phone call or an email from a locum tenens company asking if I’d be willing to cover a pulmonary practice for a few weeks or do a few ICU shifts in some community in the Midwest.

There are a lot of very legitimate reasons why bringing in a locum tenens physician makes sense. The local physician could be out on an extended medical leave or maternity leave. A doctor in the National Guard could be called up for active duty. Maybe there was an unexpected death or retirement and the replacement physician can’t start for a few months. There could be unexpected physician resignations or an unexpected growth in clinical demand and hiring just can’t keep up.

In nursing, we call those temporary workers “travelers”. In business, they are often called “temporaries”. When it comes to physicians, we call them “locum tenens”. The word comes from Latin meaning “placeholder”. I’ve seen these employees work both ways. For example, when I was the treasurer of our Department of Internal Medicine, we brought in a temporary administrative director to oversee our revenue cycle department and she brought in a wealth of knowledge and experience – we were able to capitalize on her objective analysis of our operations as an outsider looking in so that we were able to greatly improve our billing and collection efficiency. On the other hand, I have seen hospitals bring in temporary physicians who did not perform clinically as expected and resulted in a deterioration in the quality of care in those hospitals.

Many hospital medical directors and hospital credentials committees remember the bad experiences and forget about the good experiences and thus try to avoid locum tenens doctors. This month, in JAMA, we finally have some objective data to help us to decide whether bringing in locum tenens physicians is safe. In an article from Harvard, investigators looked at 1.8 million Medicare admissions covered by an internist between 2009-2014. They found that 2.1% of the admissions were covered entirely by a locum tenens physician. In addition, 9.3% of the non-locum tenens primary admitting physicians were covered by a locum tenens physician at some point during the hospitalizations.

The key finding was that there was no difference in 30-day mortality between the locum tenens physicians (8.83%) and the non-locum tenens physicians (8.70%). There were some interesting differences, however. Patients treated by locum tenens physicians had higher costs of hospitalization ($1,836 versus $1,712), longer length of stays (5.64 days versus 5.21 days), and lower readmission rates (22.80% versus 23.83%) compared to patients treated by non-locum tenens physicians. In summary:

  • No difference in mortality
  • Longer length of stay
  • Higher cost of hospitalization
  • Lower readmission rates

There were also some interesting demographic differences. Locum tenens physicians were more common in Southern and Western United States. They were also more common in smaller rural and suburban hospitals (as opposed to urban hospitals) and in public hospitals (as opposed to private hospitals).

A recent survey of healthcare organizations indicated that 85% use locums tenens at some time. Although you might think that locums tenens primarily attracts younger, more mobile physicians, it turns out that 75% of locum tenens physicians are over age 51, that is, toward the end rather than at the beginning of their careers. When considering hiring a locum tenens physician in your hospital, it is important to understand the doctor’s motivation to do locum tenens work – there are “good” reasons and there are “bad” reasons:

The Good Reasons For Being Locum Tenens:

  1. Desire to visit different parts of the United States or to visit family members residing in different parts of the country.
  2. Desire to try out a hospital practice or a part of the country before committing permanently (like dating before committing to marriage).
  3. Wanting to scale back clinical practice as a bridge to retirement.
  4. Flexibility in scheduling and ability to have extended time off during the year.
  5. Preferred lifestyle.
  6. Enrichment of professional experiences by practicing in multiple locations to improve clinical abilities.
  7. Better pay.

The Not So Good Reasons For Being Locum Tenens:

  1. The physician does not get along with other people and cannot maintain lasting relationships.
  2. The physician has substandard practice and cannot hold a job for a long period of time.
  3. The physician does not want to be invested in the long-term success of an organization.
  4. Better pay (this can be either a good reason or a bad reason, depending on the circumstances.
  5. The physician has become burned out and is just trying to stay employed.

When considering a locum tenens physician, the hospital will most often be dealing with a locum tenens company as an intermediary. It is important that the hospital stick with its usual credentialing process to vet the physicians – there can be a tendency to delegate some of the credentialing steps to the locum tenens company with the assumption that they are as thorough or have as high of standards as the hospital’s credentials committee. However, that is not necessarily the case. The locum tenens company is selling you a product, namely the doctors on their list and they will be motivated by trying to make a sale rather than by trying to improve your hospital’s quality of care. There is also the belief that because the locum tenens physician will only be there a short while, that the hospital can live with lower standards than they would require for a regular permanent physician. However, remember, it is always harder to get someone off of the medical staff than to put them on in the first place and if that physician decides to stay in the area and now has regular medical staff privileges, he/she could decide to continue to practice at the hospital long-term. Also, a bad doctor can do a lot of damage to your hospital in a short period of time. There is also the issue of cost – locum tenens physicians will usually be more expensive than a regular, permanent physician.

Some large physician groups will have an internal locum tenens group in order to fill temporary vacancies at the various practice locations that they have. Although you can be a bit more sure of what you are getting in this circumstance (since these locum tenens physicians are actually employed by the physician group), they still require the regular vetting you use for any other new physician, including contacting references from past locations where they have practiced.

The use of locum tenens physicians is becoming more and more common. Most hospitals in the U.S. will be using at least some locum tenens physicians in the next year. The new study indicates that the overall quality of care by locum tenens physicians is good. However, the hospital still need to be sure that the individual locum tenens physician’s motivations for his/her career choice will mesh with the hospital’s culture and goals.

December 7, 2017


Inpatient Practice

Improving Inpatient Pain Satisfaction Scores: PAINting Expectations

One of our surgeons always has better pain management scores than anyone else. So, I asked our nurses why and they told me.

Every month, I review our hospital’s HCAHPS survey scores that measure patient satisfaction about their inpatient hospital stay. Two of the questions on the survey are about inpatient pain management:

  1. During this hospital stay, how often was your pain well controlled?
  2. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

Pain control is particularly important in surgical patients. This particular surgeon does exclusively one type of surgery. She is very good at it but it is inherently one of the most painful surgical procedures that we do. It turns out that she uses the same pain medications that all of the other surgeons use, keeps her patients in the hospital for a normally expected amount of time, and uses the same physical therapists that work with all of the other surgeons. So, I was curious, why do her patients rate her so highly for pain management compared to everyone else?

The one thing that was different was setting expectations for her patients’ post-operative pain. In the office, before surgery, she tells them that they are going to have pain. In the pre-op holding area, she tells them that they are going to have pain and that pain medications will reduce but not eliminate their pain. In the post-op recovery area, she tells the patients and their families that they are going to have pain. When she gets ready to discharge them, she tells them that they are going to have pain when they get home.

She doesn’t try to scare the patients out of having their surgery but she she is honest about what they are going to feel. When pain is expected, it is much easier for patients to manage and when pain is unexpected, it is much harder to manage. I like to think of this as PAINting expectations for post-operative pain. The patients should expect that medications and therapy will keep their pain at about a 6/10 but prevent their pain from being a 9/10. Then, when their pain is actually a 6/10, then the patients feel that their pain was appropriately managed and their HCAHPS survey questions will be higher. If they were expecting it to be a 1/10 and it ends up bing a 6/10, then they will feel that their pain was not well-controlled.

It turns out that one of the best ways to improve pain management perceptions in surgical patients is to improve pain expectations for the post-operative period. This starts in the doctor’s office, continues in the recovery room, and continues on the hospital ward. It is something that the surgeon, the anesthesiologist, the office staff, the hospital nurses, and the physical therapists can all do. The solution is not to prescribe higher doses of opioid pain medications. The most important part of pain management is painting expectations for pain control.

November 20, 2017

Inpatient Practice Intensive Care Unit

Should We Stop Using Intravenous Saline?

Saline has been the go-to intravenous solution for decades. Every year in the United States, more than 200 million liters of saline are given to patients. Two studies presented at this week’s American College of Chest Physicians meeting indicate that we may have it all wrong and that we should NOT be using saline for most patients.

Saline is an isotonic crystalloid solution meaning that it has the same osmotic pressure as blood. For years, we thought that isotonicity was all that was important and that the specific electrolyte constituents did not really matter. Now, it looks like it does matter. There are 3 commonly used isotonic IV crystalloid solutions: saline, lactated Ringer’s, and Plasmalyte. They have significantly different compositions as can be seen in this table. Of particular note, the concentration of chloride in saline is about 50% higher than the concentration of chloride in blood. This has raised questions about whether this chloride can be harmful by creating a hyperchloremic metabolic acidosis or by other adverse effects of excessive chloride.

In the SMART study, 15,802 patients admitted to the ICU were randomized to receive either saline or a balanced IV solution as their maintenance and resuscitation solution. The balanced solution was either Ringer’s or Plasmalyte, at the clinicians preference (Ringer’s was used 90% of the time and Plasmalyte was used 10% of the time). The results showed that patients receiving saline had a 15.4% incidence of a composite outcome of death or adverse renal events compared to 14.3% in patients receiving a balanced solution. This translates to a 1.1% increase in the composite score of death, need for dialysis, or persistent renal dysfunction. Patients who were septic had the greatest adverse outcome difference with saline compared to a balanced solution.

In the SALT-ED study, 13,347 patients admitted to a non-ICU nursing unit were randomized to receive either saline or a balanced IV solution. The main outcome was the “MAKE30” which was a composite score of hospital-free days and adverse kidney events. Once again, the patients receiving saline did worse with a 5.6% MAKE30 versus 4.7% for the patients receiving a balanced IV solution. The overall hospital length of stay was the same. Patients receiving saline had a significantly higher blood chloride level and lower blood bicarbonate level during their hospitalization.

These are pretty compelling studies and they build on other recent studies that have indicated that patients receiving saline have a worse outcome than those receiving balanced crystalloid solutions. But what about colloid solutions? One of the most common colloid solutions in use is hetastarch, but in a trial comparing hetastarch to crystalloid solutions in resuscitation of patients with sepsis, hetastarch also was associated with an increase in renal disease and an increase in death. A second study of hetastarch compared to crystalloid in 7,000 patients in an intensive care unit with multiple diseases (not just sepsis) also showed an increase in adverse renal events with hetastarch compared to crystalloid.

At this time, we still don’t know what the ideal intravenous fluid is for resuscitation and fluid maintenance. For example, there are no head-to-head comparison studies of lactated Ringer’s solution to Plasmalyte. Furthermore, there are any number of other crystalloid solutions that could be created using biologic electrolytes that have not yet been used in medicine and it is likely that one of these could be superior to any of our existing crystalloid solutions.

The recent Baxter saline bag shortage gives us an opportunity to begin to move away from saline to balanced crystalloid solutions. But the use of saline is so ingrained in medicine that change will not come easily or quickly. However, it is now time for us as hospital leaders to promote the use of lactated Ringer’s and Plasmalyte instead of saline.

November 2, 2017


Inpatient Practice

The 2017 Saline Bag Shortage

One of the casualties of Hurricane Maria was the Baxter Healthcare. Baxter makes supplies and fluids for intravenous therapy and also makes products for dialysis. One of Baxter’s manufacturing plants is in Puerto Rico. When the hurricane knocked out power to the island, the plant was not able to make products. The products that they make in Puerto Rico are small bags of saline known as “Mini-Bags” and “Viaflex Containers” and the Puerto Rico plant is the only manufacturing site for U.S. distribution of these products. These are plastic bags containing 50 ml or 100 ml of sterile saline. In the hospital, we use these in a number of situations: as a solution to run through IVs when the IV rate is KVO (“keep vein open” – a very slow rate with just enough saline going in to prevent the IV from clotting off, generally < 50 ml/hour) and when making an “IV piggyback” to put intravenous medications in. Although the Baxter factory is still functional, they are running off of generator power and curfew on the island limit them to running only 1 shift per day.

The background information is on the FDA’s website. Baxter has other manufacturing facilities in Ireland and Australia and the FDA has given permission for Baxter to import saline bags from those countries. But in the meantime, there are shortages and hospitals have to deal with the shortage. Here are some practical things that the hospital can do:

  1. For medications that can be pushed through a syringe (for example, low-dose furosemide), use a syringe rather than a small bag of saline.
  2. Eliminate the use of “KVO” IV rates and just cap off unused IVs with a saline well.
  3. Use 1,000 ml bags of saline instead of 250 ml or 500 ml bags (the 1,000 ml bags are not on shortage).
  4. Convert patients from IV to oral medications whenever possible.
  5. Eliminate IV fluids once a patient is able to take oral fluids.
  6. Instead of IV saline, use a different IV solution that is not in short supply, such as 0.45% NaCl, D5W, D5/0.9, D5/0.45, or Plasmalyte.

October 20, 2017

Inpatient Practice

Improving Doctor Communication

The HCAHPS survey measures patient satisfaction with various aspect of their hospitalization. One of the sections of the survey is about doctor communication with the patient. Because a hospital’s HCAHPS results are publicly available, hospitals want to do everything they can to keep their scores up. As a hospital medical director, one of my jobs is to keep the doctor communication scores high.

We are able to analyze our HCAHPS results by nursing unit, physician group, and individual physician. I always find it remarkable that there are some physician groups that routinely score in the national top percentiles for doctor communication. On the other hand, there are other physician groups that routinely score in the bottom percentiles nationally for doctor communication. I’m very familiar with the quality of medical practice that all of these groups practice and it is pretty similar. But the HCAHPS survey does not really measure quality of care, it measures patient’s perceptions about their care. So, it is not good enough to just provide great medical care to the patient, you have to provide great communication to the patient. To use a restaurant analogy, you can serve the absolute best food in town but if the waiter is a jerk, you are going to rate the restaurant poorly. Here are some practical things that doctors can do to improve the patient communication scores on the HCAHPS surveys:

  1. Commit to sit. Patients are generally laying or sitting up in a hospital bed. If a physician comes into the room and is standing while talking with the patient, then the communication lines between the doctor and the patient are not aligned. On the other hand, if the physician sits down when rounding on that patient, several things change. First, the doctor’s face and the patient’s face are on an equal level and this imparts more of a 2-way communication perception as opposed to the doctor towering over the patient and lecturing to them. Second, the patient’s perception of time changes – the patient will perceive the doctor who spends 3 minutes in the room sitting as having spent more time with them than the doctor who spends 3 minutes in the room standing. Third, simply sitting will create more of an impression of caring about the patient.
  2. Don’t be a one-and-done. A lot happens to a patient every day in the hospital. They have tests, then get new medications, and they have changes in their symptoms. If the doctor just rounds on the patient once in the early morning each day, then that patient will perceive that the doctor is less engaged in the patient’s care. On the other hand, doing formal rounds in the morning and then brief follow-up rounds on the patients in the afternoons can be reassuring to the patients that the doctor is keeping track of the patient’s status and test results and also creates more of an impression that the physician cares about that individual patient.
  3. Round with the nurse. Joint rounds, when the nurse and the doctor both go into the patient’s room together, can make a big difference in doctor communication scores. It creates an impression by the patient that everyone is on the same page – that is, that the doctors and nurses are all communicating with each other about the patient. It allows for the nurses to get a lot of information from the doctor about the plans for the day, etc. so that the nurse does not need to page the doctor later in the day with questions about the patient. It allows the nurse to bring up information about the patient’s condition that the patient might night think or know to mention to the doctor (like whether the Foley catheter can come out or that the patient had a fever earlier in the day). However, it is important that these joint rounds occur in the patient’s room and not just in the hallway in order to affect the patient’s perception of doctor communication.
  4. Speak the patient’s language. For a patient who speaks a foreign language and doesn’t speak English, this is pretty self-explanatory: you get a translator. But every patient has a different level of healthcare literacy and the words that the doctor chooses can make a big difference in whether the patient really understand what the doctor is saying. In our hospital, when a doctor talks with a patient, the complexity of medical terminology used by the doctor is inversely related to how many years that doctor has been practicing. Often, you’ll hear a resident say to a patient: “The cath showed you have a cardiomyopathy with an ejection fraction of 30% so we’re going to start a diuretic and an ACE inhibitor”. An hour later, the more experienced attending physician will walk into the patient’s room and say: “The heart test showed you have heart failure and the heart is not pumping very well so we’re going to start you on a water pill and a heart failure pill”. The bottom line is you need to avoid medical jargon.
  5. The patient only remembers 3 things. Being an inpatient is pretty overwhelming and patients are trying to remember lots of stuff, at a time that they usually feel pretty lousy. If you tell the patient 6 things about their condition, they are only going to remember 3 of them. So, be judicious in information so that the patient remembers the 3 things you want them to remember rather than the 3 least important things of the 6 that you told them about. Having a white board with a marker to write with in the patient’s room can be a great way of reinforcing information and helping the patient’s family know what is going on that day; for example, write down the name of the new drug being started or the tests/therapies planned for the day. At the end of the encounter, summarize the key points that you want the patient to remember – they will remember the last things you said better than they will remember the first things that you said.
  6. Listen to the patient. This is probably the hardest part of doctor-patient communication in the hospital. The doctor is under enormous pressure to get in and out of the patient’s room so that he/she can order all of the tests that need to be ordered, get their progress notes written, review consultant reports, get the next patient admitted, and get other patients discharged. But communication is a 2-way event and the patient will perceive that the doctor is a better communicator if that doctor listened to what the patient had to say in addition to talking to the patient. Try to finish each encounter with “What other questions do you have?”.
  7. There is more to the patient than just a disease. Take time to find out a little bit about the patient other than their lab tests and x-ray results. Learn a little about their family, their recent travels, their occupation, their heritage, or their hobbies. The patient will perceive that the doctor is interested in them as a person and not just as customer.
  8. Hospitalist face cards. The patient sees lots of people in the hospital and usually has a hard time remembering who is who. Giving the patient a card with the hospitalist’s name and photograph goes a long way in helping the patient sort out all of this information. Furthermore, it changes the mindset of the patient from “That is the doctor” to “That is my doctor”.
  9. Give the doctor feedback. We give residents and medical students feedback on how they communicate but the attending physicians rarely get feedback. Having a senior physician or a member of the hospital’s patient experience staff round with the physician to give them feedback on their communication style can be very effective in fine-tuning that doctor’s communication with the patients.
  10. Incentivize communication. In a previous post, I wrote about why you can’t pay hospitalists by the RVU. As with anything in life, you get what you pay for and if all you pay for is patient volume, then you get patient volume. But if you bonus hospitalists on their doctor communication scores, you’ll get better communication scores.
  11. Don’t let the computer get in the way of the patient. Either do the computer charting after you walk out of the patient’s room or, if you must use the computer in the hospital room, maximize eye contact with the patient and minimize the amount of time you are looking at a computer screen.
  12. Respect the patient. Patients often feel like a piece of medical merchandise. Treat them like a person by knocking on their door before entering their room, addressing them by their name, introducing yourself, asking them for permission to do a physical exam before laying hands on them, be aware of your body language (fidgeting, checking your cell phone, etc.), and avoid interrupting the patient.
  13. A picture paints a thousand words, and so does an x-ray. People fear ghosts because they can’t see them. Once you actually see something that you are afraid of, it usually isn’t quite as scary as it was before. Showing a patient what the x-ray or CT scan abnormality is can de-mystify their disease and help them understand it. Having a bedside computer or tablet can help the patient see what the problem is.

Perhaps the most important lesson comes from a quote by George Bernard Shaw: “The single biggest problem with communications the illusion that it has taken place.”

October 10, 2017

Inpatient Practice Medical Economics

The 2017 Epinephrine Shortage

Epinephrine is the most common drug used to resuscitate patients in cardiopulmonary arrest. EMS squads keep it on hand during every emergency run and hospitals contain it in their code carts. Epinephrine comes in a variety of strengths and dosing sizes but during cardiopulmonary resuscitation, the most commonly used size is the pre-filled 10 ml syringe containing 1 mg of epinephrine (1:10,000 concentration). This spring, a shortage of these epinephrine syringes occurred and now hospitals and EMS units are struggling to develop alternatives.

Epinephrine has been used for more than a century. It was first extracted from adrenal glands by Napoleon Cybulski in 1895 and he called the extract “adrenalin”. The next year, the extract was used in eye surgeries. It was first synthesized in the laboratory in 1904. Like many drugs that were in use before the FDA was created in 1927, epinephrine was never formally approved by the FDA. But the FDA not only approves drugs, it also approves devices used to deliver those drugs. Recently, there was a lot of controversy when Mylan, the manufacturer of the “EpiPen”, increased its price from $103 to $608. In this case, it wasn’t the epinephrine contained in the EpiPen that was at issue, it was the EpiPen device – the FDA has authority over both medications and devices and Mylan had the corner on the EpiPen device – this is what allowed them to increase the price by more than 500%.

Drug shortages have been getting less frequent each year for the past 6 years. In 2011, there were 251 drug shortages reported  to the U. S. FDA and by 2016, this had fallen to 23 new drug shortages. The most common reason for drug shortages relates to manufacturing quality – either problems directly related to the manufacturing process or problems with logistics, such as production delays.

One of the factors that has made the United States vulnerable to medication shortages is a smaller number of manufacturers producing low-cost, older generic medications. These drugs are generally less expensive than more newly developed drugs and so there is relatively little margin on them. A 1 mg amp of epinephrine costs about $6 whereas a single pill of the new cystic fibrosis medication, ivacaftor, costs $510 (and it has to be taken twice a day for the rest of a patient’s life!). Therefore, if there is a production problem with a drug like ivacaftor, the manufacturer will be very strongly motivated to put all necessary resources into quickly resuming production or else the company’s stock will drop and the company’s board of trustees will be livid. On the other hand, there is less business pressure if the disruption involves a medication that has only a few cents margin per dose. When a medication becomes too inexpensive, some manufacturers will drop out of the production marketplace, often resulting in only one or two companies making a drug and often making that drug in a single factory.

In the case of epinephrine, the main manufacturer of the 1:10,000 pre-filled syringes are Amphastar Pharmaceuticals and Hospira (a subsidiary of Pfizer Pharmaceuticals). On May 10, 2017, Amphastar stopped distributing a different formulation of epinephrine, the 1 mg/ml 30 ml vials. On that same day, Pfizer, stopped distributing their 1 mg/ml epinephrine product. Amphastar experienced production delays for their 1:10,000 syringes due to increased demand and does not project being able to increase production in order to meet demand until October 2017.

So, what is a hospital to do when facing a shortage of epinephrine?

  1. Reduce the number of syringes stocked in hospital crash carts. Many hospitals will keep 5 amps of epinephrine in the crash carts (each contained in its own light-proof box). Consider decreasing this to 3 or even 2 per cart.
  2. Remove epinephrine from locations that rarely use it, such as the Pyxis machines on regular nursing units.
  3. Utilize the 30 ml multi-dose vials (1 mg/ml) in situations when multiple amps of epinephrine are required (prolonged resuscitation efforts, etc.). Be sure that the pharmacists are well-versed in the bedside mixing of epinephrine (i.e., 1 ml of the multi-dose epinephrine diluted in a syringe with 9 ml of saline). Also be sure that there are labels on hand so that the newly mixed epinephrine can be labeled correctly by the pharmacist.
  4. Consider using the more concentrated 1 mg/1 ml (1:1,000) ampules of epinephrine if there are sufficient stocks of this dosing concentration in your hospital but remember to dilute these 1 ml doses into 9 ml of saline prior to injection. Be sure that there are labels for the newly diluted 1:10,000 syringes containing 10 ml total.
  5. Check the expiration date on existing stock of epinephrine. When there are drug shortages, the FDA will often approve an extension of expiration dates in order to preserve existing stocks of medications. In the situation with epinephrine, the FDA granted Pfizer a 9-month extension of the expiration dates for most lots of 1:10,000 epinephrine. A complete list is available on-line.
  6. Avoid bulk compounding in the pharmacy because epinephrine is susceptible to light, air, and pH, resulting in a short stability when prepared in a regular pharmacy.

Because generic drugs are cheap, they are less profitable to make. Therefore, the financial advantage will go to the company that can mass-produce large amounts of the drug as inexpensively as possible. In a free market economy, this often results in fewer manufacturers in the market and results in shortages when one of these manufacturers has production problems. Therefore, drug shortages are here to stay for the foreseeable future.

July 30, 2017

Inpatient Practice Outpatient Practice

The Future Of Telemedicine Is Now

Telemedicine. It is an idea that just seems to make so much sense but it has had a hard time getting much traction in the United States. But recently, economic forces are causing telemedicine to become a viable option in a number of areas. Here is how we are using telemedicine in our hospital:

Prison medicine.

For more than 25 years, we have had a telemedicine program with the Ohio Department of Corrections. Inmates with medical conditions requiring more than basic primary care go to a video camera set up in the infirmary of Ohio prisons where there is 2-way video communication with a specialist at the Ohio State University Wexner Medical Center. There is a nurse at the prison-end who can do physical examination directed by the physician at the OSU-end and there is an electronic stethoscope for auscultation.

Why it works: It is cost effective for the Department of Corrections. It costs a lot to transport an inmate across the state to be seen by a physician in person and there is security risks. It is far cheaper for the Department of Corrections to pay our medical center for telemedicine visits. Patients that do need in-hospital care for medical or surgical conditions are admitted to a locked-down prison unit at University Hospital.


Patients who come into the emergency department at University Hospital East are evaluated by a two-way video camera system by a psychiatrist located in a remote location. The psychiatrist can determine if the patient needs inpatient hospitalization in a psychiatric hospital or if they can be safely discharged from the ER.

Why it works: Our psychiatrists are based out of the main University Hospital campus where the inpatient psychiatry hospital is. My hospital, University Hospital East, is 9 miles away. A psychiatrist seeing emergency department and psychiatric observation patients would need to leave those patients and drive over to our hospital to see psychiatry patients in the emergency department. Telepsychiatry permits the psychiatrist to evaluate patients remotely, thus keeping the number of patients being boarded in the emergency department for psychiatric evaluation down.


Patients presenting to the emergency department with an acute stroke get a quick screening head CT and then a stroke neurologist (a neurologist who has done an advanced fellowship in stroke medicine) evaluates the patient by a video system. The stroke neurologist then makes a decision about whether the patient should receive t-PA (a blood clot dissolving medication).

Why it works: From the time a patient with an acute stroke arrives in the emergency department, we only have an hour for the emergency department physician to do his/her assessment, get a head CT to be sure that there is not a tumor or bleeding in the brain, be assessed by the stroke neurologist, and then get the t-PA. If you go much beyond an hour, the stroke becomes irreversible. There are not enough stroke neurologists to have one in every emergency department 24-hours a day so the solution is to have a central “hub” (our main University Hospital) and then a few dozen “spoke” hospitals that can use telemedicine to connect to the stroke neurologist at the hub. My hospital, University Hospital East, is one of many spoke hospitals affiliated with Ohio State.


Hospitalist at University Hospital East can take a photo of a rash or skin lesion and load it into our electronic medical record. A dermatologist at a remote location can then look at the photo and determine if there is enough information to make a diagnosis, if a punch or shave biopsy of the skin is required (which can be done by our family physicians or general internists), or if an in-person consult is required.

Why it works: We don’t have a lot of dermatology consults in our hospital. The cost of a dermatologist driving 15-20 minutes each way to come to our hospital to see a consult is not cost effective – they can see a lot of patients in the office in that 30-40 minutes. Because most of the time, the dermatologist can make a reasonably confident diagnosis from the photograph, it allows the dermatologist to see more patients rather than wasting time in the car. We have also extended the teledermatology program to Ohio State primary care physicians who can take a photo of a rash using their smartphone, load that image into the electronic medical record, and then the dermatologist will give an opinion within 24 hours – far simpler than waiting 2 weeks for a new patient appointment; the medical center is currently funding this program since it is not covered by private insurance.


This one is a natural product of the computerization of radiology images. A radiologist can pull up an x-ray or CT scan from any computer, anywhere in the world, and read the radiology study.

Why it works: The images on the computer are every bit as good (and usually better) than the images on old-fashioned x-ray films. We have x-ray sites all over the city and this allows the radiologist to be in one location and give an immediate interpretation of an x-ray done at any of these sites and report them on our electronic medical record.


At University Hospital East, we have a general pathologist on site. But sometimes, you need a pathology specialist to review and interpret the microscope slides of a biopsy. Also, we have a procedure called “endobronchial ultrasound” where a needle aspirate of a suspicious lymph node or lung mass is taken during a bronchoscopy using a tiny ultrasound at the tip of the bronchoscope to guide the needle to the right place. Normally, there a cytopathologist (a pathologist who specializes in looking at cytology slides) does an immediate stain of the cells removed from each pass of the needle to tell the bronchoscopist whether there is enough cells to make a cancer diagnosis or whether additional passes of the needle are required. In telepathology, the microscope slide is loaded into a special microscope that can be manipulated by a pathologist viewing the images from that microscope over the internet, miles away.

Why it works: The cytopathologist can be at one location and review slides being done simultaneously from multiple other locations without having to travel to multiple sites in a single hospital or to multiple hospitals within a hospital system. Also, if a surgical procedure runs late, an on-call pathologist at one hospital location can do a frozen section analysis of a specimen at a different location so that a second pathologist does not need to be called in to do the frozen section.

In the past, telemedicine has always been constrained by reimbursement: Medicare and insurance companies did not want to pay for something seen as less than a “real” face-to-face encounter. But there are other economic factors in play – it is too costly for hospitals to have a stroke neurologist, psychiatrist, cytopathologist, dermatologist, or radiologist physically located at all sites within a large medical center at the same time. So even though many of the telemedicine services mentioned in this post are not reimbursable, they are financially viable because they obviate the need for a high-cost specialist to have a lot of down time driving from one location to another.

If we move toward a capitated health care model, we will likely see telemedicine incorporated into other practices. Just imagine how happy patients would be to get a ring on their Skype program when their doctor is ready to see them, rather than having to drive to their doctor’s office, park, wait in the waiting room, and then wait again in the examination room to finally see the doctor who is (as all doctors always seem to be) running late. The only thing holding us back is economics.

June 6, 2017