Not to put it too harshly, but with all the money that is poured into healthcare in this country, we in the medical profession should be ashamed of those statistics. And actually, hospitals aren’t being asked to reckon with this situation, rather they are facing significant financial loss if they don’t shape up.

Various financial incentives, including provisions in the Affordable Care Act as well as state initiatives (in Maryland, there is the Admission Readmission Revenue, or ARR, program), have put nearly every hospital on the hook for reducing readmissions. It is not an easy nut to crack.

Just this week, Reuters reported on a study on patients who were given information packets, personal assistance, and even an “on-call medical librarian” to answer any questions regarding prescriptions they received after being discharged from the ER. None of these strategies made a difference.

Other programs aim to reinvent the hospital discharge process. Still others seek to connect newly discharged patients with community services like home healthcare. And yet perhaps the most aggressive strategy is one rarely, if ever, employed: sending healthcare providers directly from the hospital into the patient’s home in the immediate days and weeks following their discharge.

The fact is, for many patients, their medical conditions are just the beginning. When it comes to the sickest of the sick, the patients who are often responsible for a hugely disproportionate amount of healthcare costs and services, there is often a tangled web of interconnected problems, from poverty, to mental illness, to family problems, which can interfere with and ultimately sabotage the healthcare industry’s best efforts to provide care.

Sending healthcare providers directly into their home is a start. Until recently, hospitals had few incentives to experiment with these types of transitional care programs. If a patient was readmitted shortly after being discharged, it often meant more revenue for the hospital, not less. Only now is it beginning to be possible to provide care directly to the patient in their home, absent the incredibly expensive infrastructure that surrounds a hospital visit, and have it both be a net savings to the healthcare system and profitable enough to the care provider to make it feasible.

Creating these transitional care programs is often like building a car as you drive it. There are many challenging problems, from a frustrating scheduling process in which the patients themselves may not show up to appointments in their own home, to finding the balance between providing healthcare and fixing other problems that may impact a patient’s health. These problems can be as mundane as helping a patient pay an electric bill to get the electricity turned back on so they can use a home medical device. Finding the line between patient care and social work is an ongoing challenge.

Still, transitional care programs are ripe for innovation, for forward-thinking providers who are willing to do the difficult work of making these programs a success. For hospitals, even seemingly modest success, such as preventing a few dozen readmissions, can yield a financial benefit – and preventing more than that could save a hospital millions of dollars.

- Michael Cetta, MD (Read other posts by Michael Cetta)

That is not to say that fee-for-service will not survive in certain circumstances. Particularly in emergency care, it is difficult to integrate into a simple, population-based formula. Emergency care by its nature is episodic and in many times unexpected. On the other hand, we know that some care received in the emergency department is due to lack of access as well as preventable conditions, many of which can and should be handled in a different, lower cost care setting.

But the historic fee-for-service model that incentivizes procedural skills over outcomes is well entrenched in our healthcare system. The question is how do we move from a fee-for-service model to a value-based model and manage our practices and businesses until we get to the other side?

Once choice is to continue to innovate and gather data on outcomes, and link those outcomes to gain sharing arrangements via shared savings plans across multiple specialties. There are obvious ways to do this, including recognizing that a surgeon who does not operate may be just as important as a surgeon who provides the lowest cost operation.

It makes sense to expand shared savings past primary care, patient-centered medical homes to larger multispecialty groups that can have a greater impact on a broader range of diseases and overall health. These are hard conversations to have with caregivers and patients alike. It requires investments of time and technology on the provider’s part as well as an assumption of more responsibility on the patient’s part.

Beyond the difficult conversations though, there is real pushback (call it resistance, reluctance, or something else) by the payers to this sort of arrangement. MEP has proposed both gainsharing arrangements and shared savings programs as a way to move away from a fee-for-service model. The response we have received from the insurers is that it’s a great idea but they do not know how to structure such an arrangement in the current environment. It is frustrating for those who want to transition to value-based reimbursement when major payers continue to negotiate on a Medicare fee-for-service basis.

It is also time for medical specialties in shared geographic areas to begin to band together and partner with hospitals to deliver the value that the healthcare system both needs and requires. If physician groups fail to take advantage of this opportunity, they will be the odd man out as payment mechanisms change, and as hospital systems become the driving force in delivering care to their collective patients.

In a country which has historically both depended on and benefited from the entrepreneurial spirit of its citizens, the idea of meeting those needs through innovation in healthcare is obvious. As we leap into this unknown, those who continue to focus on better outcomes and lowering costs while leading our patients and ourselves to the other side will be to the benefit of all.

- Angelo Falcone, MD (Read other posts by Angelo Falcone)

That’s according to two recent studies in the Journal of the American Medical Association which looked at the effects of duty-hour restrictions, which were instituted in 2011 as part of an effort to “protect patients from errors made by sleepy doctors.” Oops.

I must say, having trained in both the pre and post duty-hour restriction eras (I had four years of military service sandwiched in between), I’m not surprised by the findings.

I’ll give you the Cliff Notes here:

1. Adding duty-hour restrictions did not increase the amount of sleep residents get overall per week. This is not surprising. Sleep is a commodity, but so is free time. And given the choice, most twenty to thirty year olds would gladly trade sleep for some extra free time. Especially those with young children and family obligations.
2. Twenty percent of the residents surveyed for the study screened positive for depression. Again, not surprising given what we know about the inherent stressors of residency training, the high incidence of mood disorders in health-care workers in general, and the aforementioned sleep problem. And while many residency programs (including my alma mater George Washington) have formally adopted resident wellness as part of their curriculum, I think the ACGME will have a difficult time putting a dent in this number by duty hour restriction alone. Residency is a bear.
3. Medical errors harming patients increased 15% to 20% among residents with duty-hour restrictions compared with residents who worked longer shifts.

To me, this last finding is the most interesting one of the study. Herein lies the obvious unintended consequence of duty-hour restriction – the discontinuity of care and opportunity for the introduction of hand-off errors.

Don’t get me wrong – I happen to be in favor of some duty-hour restrictions on residency trainees. Having fallen asleep holding a surgical hook as an intern myself, I can attest to the absurdity of 30 hours straight of anything, especially patient care.

I think the takeaway from this study, however, is that teaching and rehearsing effective hand-off procedures is more important than ever. At MEP, universal bedside sign outs are a fundamental part of our practice model. If you haven’t tried them in awhile, you really should.

Bedside sign outs provide tremendous piece of mind for the departing physician, the assurance that what you are handing off to your colleague is not in fact a complete and utter mess. They put the receiving physician in a much better position to respond to events that will inevitably occur just moments after the departing physician has made it to the parking lot. And besides the obvious benefits of improving communication and patient safety, they are a HUGE satisfier for the patient and their family, allowing the opportunity for clarifying questions on treatment plans and disposition.

It’s what you would expect from your mother’s doctors, right?

- Jesse Irwin, MD (Read other posts by Jesse Irwin)

Kim Jong Un’s bizarre anti-US saber rattling: nuke tipped missiles aimed at a Colorado Springs (located squarely in the heart of Texas). On April 15 he promised hellfire to commemorate his grandfather, the patriarch of his dynasty.

Then, at 3pm that Monday, came two near-simultaneous explosions at an event known for dignity, endurance and achievement. Three young people lost their lives, dozens lost limbs, bystanders and first responders ran to the rescue. The EMS, hospitals and Emergency Departments of Boston absorbed the unexpected horror without hesitation.

The world of Emergency Services was ready. “No matter how much drilling you do, you will never really prepare yourself for what this is like,” said Ron Walls, ED chairman at Brigham and Women’s Hospital, where many victims were brought. More than just drills: an email from ACEP went to every member ER doc on how to treat blast injuries and current advice on the proper use of tourniquets.

That’s one side of how far we’ve come since 9/11. The other component is information preparedness. We knew there were going to be images. And cell phone tracking. That the bomber(s) would be ID’d fast.

Tuesday and Wednesday followed with further evidence of a world better, worse and same as before: ricin letters to the President and Senate – followed by a lightning-fast ID and capture. A failed vote on the least controversial and best supported measure to improve gun sale background checks, interrupting the reports of the survivors conditions, the first glimpses of the suspects and the identities of the dead. To me, these are mind-bending paradoxes: we love and support our cops and EMS, but we can’t put the brakes on the dangers they warn against. As a society we work so spectacularly in times of crisis, but we cannot derail the will of either a few deranged lone extremists or the influence of a few powerful lobbyists.

And then, just when it seemed as if we had used up all our fair share of shocks, came the “nuke”-like explosion near Waco at a fertilizer plant. It probably got lost in the tornado of events, but the image of first responders in the night is the most impressive thing I’ve seen in a long time happened: fifteen miles from the middle of nowhere, in a town with fewer people than a Bethesda hi-rise, in the middle of the night hundreds upon hundreds of first responders, ambulances and medics all arrived and co-ordinated a completely unplanned rescue effort as if it was DNA itself uncoiling and creating life.

If you’ve only seen the picture of the blast or the tower of smoke, look at this picture and marvel at the amount of preparation, rehearsal, discipline and trust goes into creating a chain of hope like this. It’s a reflection of trust and caring in our bones and investment in our communities.

“It’s times like this that bring out the best in everybody,” said Dr. Richard Wolfe of Beth Deaconess Hospital in Boston, speaking about the response to the marathon bombings. “People are willing to help, they’re willing to collaborate. Egos dissipate and people tend to work together the way you just don’t see on a regular basis. From my standpoint, watching how well the teams worked, …was a validation of what emergency medicine is all about, and what emergency medicine training is.”

All of this was unimaginable a week ago. Planned for, rehearsed, but still somehow not quite real. Neither the bitterness and loss of attacks here at home nor the beauty and raw power of co-ordinated emergency services magically appearing from thin air. A Facebook picture captures it best: the oceans of runners taking off at the start if the race, with the caption: “you’ve just pissed off a lot of people who can run faster than you and never give up. Real smaht.”

- Julian Orenstein, MD (Read other posts by Julian Orenstein)

MEP is pleased to release the following letter from the wife of a patient in our Transition Care program. We would like to thank Melissa Farkas, Kathy McKenny, and the entire the Transition Care team for their hard work in making this program a success. We also want to thank Barbara Everly, for sending the letter and giving us permission to release it. 

Dear Melissa:

In addition to thanking you and your staff, there is much I would like to say about the new program, Transition Care. The care provided to my husband following his last hospitalization was superior. The educational support provided to me to administer his day to day care was excellent. I’m sure I am not alone when I say that good health is sometimes taken for granted and can turn a household upside down when it fails, reminding us that quality of life is our primary asset.

Having been employed by the hospital for over forty-seven years, with the last 20 plus years as the Director of Health and Safety with a masters level certification as a Healthcare Safety Professional through the state of Maryland, I am very much aware of the benefit of such a program. Vast changes in health care over the years combined with multiple and continuing changes in family dynamics, the economy and the never ending changing & pending regulations set the stage for new programs. Programs championed through the hospital I feel best address the needs in our community and surrounding communities. And, I am aware new programs created by the hospital are very complex but fill the gap to meet the health care needs at a reasonable cost savings to the public.

The Transition Care Program, as intended, does bridge medical care to the home. The service provided to my husband definitely was the main element responsible for his recovery. Recently I read a quote by an unknown author that sums up my assessment of your new program. It stated,“The I in illness is isolation, and the crucial letters in wellness are We“. The quote in my opinion is the secret language of healing.

Struggling back to health is a long and scary period in the life of the patient and those who care for them. Innovative programs such as Transition Care certainly made the difference in moving forward to a positive outcome. I am pleased that hospital administration supported the vision necessary to make the program a reality. I hope the support will continue and marketing of the program increases its usage in our community and expands to partnering with other health care providers.

In this light as you evaluate your progress I would like to say that I am in two senior (over 55 yrs.) bowling leagues consisting of over 200 individuals who live in our community. Many of these individuals needing medical care that I am aware of and have local primary physicians made the choice to travel down the road for surgeries, etc. with follow up visits and telephone communications with the same service source once they return home to recuperate. Choice is personal however the number of individuals having complications & return surgeries with inpatient stays has truly been an eye opener to me as it is fairly obvious that having medical care in the home following their treatment could have made a difference. For this reason I’m hopeftil that some sort of partnership could be worked out so that they might be able to receive medical care services through your program. From my conversations with these individuals the primary care physicians would be the key because each one referenced contacting their PCP with problems.

Please use my letter in any way you see fit to promote your new program. I also hope you have thought of using the new program in materials for your next Joint Commission review.

Last but not least below is a partial list of some of the services and benefit provided through your staff member Kathy McKenny. She made the difference in so many ways. Please share this portion with her and express our appreciation. Tell her that Bob is up around 140 Ibs., is maintaining the proper blood pressure levels and retaining an oxygen level of 93-94 and sometimes higher. He has returned to bowling and is golfing today. The one thing he has to focus on now is rebuilding muscle.

Program Service/Benefit:

• Reviewed medical documentation from each hospital discharge.
• Reviewed and compared care received at urgent care and the hospital.
• Reviewed a chart I had made for administering medications along with continuation of the regular medications. A review was made of the timeline for all medications.
• Answers to questions put into layman terms for understanding of the medications & changes were made to the delivery timeline to ensure other problems were not created.
• Discussions regarding the benefit of each medication. A refill order was made for lidocaine to help the swallowing of ground up food.
• Changes to food grouping were recommended so that the food and medication would not interact and cause increased intestinal problems.
• Suggestions and tips for lessening the use of oxygen with confidence and movement around the house.
• Suggested ehange to regular medications, particularlyblood pressure medication to ensure that the fluctuationsdid not cause bleeding in the retinas and proposed time changes for monitoring.
• Assisted in formulating questions to discuss with primary care physician.
• Progress reports were prepared and submitted to the primary care physician for each visit.

Kathy displayed professional confidence, caring and friendship with each visit. My husband showed relief and signs of improvement after the first visit which I relate to the encouragement she instilled in him. He looked forward to her visits. And, as requested, she telephoned as she pulled into our driveway giving us time to lock up the dog and open the door.

Through use of the Transition Care Program Bob and I, certainly received a better Perspective of his illness; a clearer Focus of what we were facing; and a much better Vision of what we could look forward to. In other words we could see the past, the present and the future.

Again I thank you and offer any help I can to assist moving the program forward.

Sincerely yours,

Barbara L. Everly

The changes occurring in our care delivery systems have generated great interest, innovation, and yes, fear among many in healthcare, doctors included. Some recent news stories (here and here) have documented physician practices under severe financial stress, or even going bankrupt. Others note the formation of gigantic health systems (see here) and growth of Accountable Care Organizations.

So what is a physician to do when evaluating their options?

Physicians (and physician groups) have a critical decision to make. Will doctors become an employee of an entity that delivers care, or a valued partner and consultant to that entity? Both paths are available, but whether the one you choose works out for the best or turns out to be an absolute disaster depends on how deliberately you approach your value as a doctor within the healthcare system.

Thinking deliberately means putting aside the standard complaints I hear so often from doctors today about how tough their decisions are, whether it’s about rising overhead pressures, decreasing reimbursements, government regulation, or fights with insurance companies, and instead taking time to think about themselves as clinicians and healthcare practitioners.

If worrying about those pressures is too much, your choice is easy. Pick a partner and approach your local or regional health system about becoming a part of them. They have enormous resources and should be equipped to better manage this market transition, wherever it may lead. You can still complain about them being too (pick your adjective) big, ineffective, slow moving, unconcerned, etc. The reality is if you have decided you can’t provide a compelling and unique service that is worth marketing and offering then you have sealed your fate.

On the other hand, market consolidation, with more and more physicians becoming employees of large health systems, isn’t necessarily the best way forward. Suppose you or your group offer a unique service. It could be how you manage patients with high risk diagnoses, complementary and alternative medicine offerings, a unique way of managing patients with obesity or an innovative home health product.

In that case you can approach your hospital system, and others, about providing that service in a partnership setting. Partnership involves taking a risk and providing a service that someone else values. It means investing in a product or service to seek a better outcome. The system will reward you IF you have proven that it works and someone trusts that you can do it better, faster and yes cheaper than they could themselves.

That is not a bad thing. Partnerships are where innovation and ideas are fostered and honed. Some of those ideas work and deliver incredible results. Some fail because they do not deliver, address the wrong issue or are ill-timed. That doesn’t mean we should stop trying to innovate. When I speak with health system leaders I am struck that they have the same concerns about the proper positioning of resources, where they need to invest and where they are going to find good partners to help them navigate this time of transition.

Nearly all physicians do what they think is in the best interest of their patients. But the fact is, some do it better than others and deliver better results and a higher value. The value equation means higher quality, lower cost and a better patient experience.

In the end physicians, and physician groups, have a choice when it comes to their fate. The path each takes will be intentional, or not. Whether we want to admit it or not, we hold our fate in our own hands.

- Angelo Falcone, MD (Read other posts by Angelo Falcone)

But it wasn’t always like that. In 2008, before MEP took over management, it took more than two hours to get seen. Patient satisfaction was in steep decline, and LWBS was more than 5 percent. On top of that, the hospital was paying a generous subsidy to the incumbent emergency group.

This Case Study, the first of several MEP will be releasing in coming months, is the story of how MEP turned it around. We are extremely proud of the entire team at Meritus Medical Center for the work they’ve done, and their continued excellence in emergency care.

Click here to download the Case Study: The MEP Effect; Meritus Medical Center

We always knew we would live and practice medicine in Connecticut. Even before Match Day, my wife and I bought a house there. But just because we’ve been in Connecticut for the past seven years, since I completed residency at Massachusetts General Hospital in Boston, doesn’t mean it’s always been smooth sailing.

After four years on Cape Cod as an ED attending, I came to Waterbury Hospital. At the time, Dr. Craig Mittleman was the medical director there. My wife and I job shared while we started a family. When she worked, I was home with the kids, and when I worked she was home. We made it work. But other aspects of working at Waterbury left me feeling unsatisfied as an emergency medicine physician.

I and the other ED physicians were hospital employees, and in the seven years I worked there, I literally never once saw or met the CEO. Our work felt disconnected from the overall goals of the hospital, or from any goals for that matter. In the large network of providers, systems, and service lines that comprise a hospital, the emergency department can often become overlooked.

Roughly a year ago, in the midst of a merger between Waterbury Hospital and St. Mary’s Hospital, also in Waterbury, I became aware that Bristol Hospital was hiring new ED physicians. Dr. Mittleman had moved to that hospital years earlier, so I already knew him. But the hospital’s Emergency Department had recently changed management to a new, out-of-state group based in Maryland: MEP.

I did a lot of research looking into MEP. I had no idea what this whole Maryland company was all about. I talked to some of their doctors, including Drs. Jesse Irwin, Noah Keller, and Aaron Schneider their head of recruiting. I got a feel for the whole “MEP Family.” It seemed like a good group of people.

When I finally joined the team last year, though, I was blown away.

I had never known what it was like to work for a company where you know the leadership has a personal interest in your well-being. All of a sudden I was in direct contact with MEP’s CEO, its President, and others. Not only were they flying weekly to Bristol to work shifts (MEP’s CEO and other leadership continue to periodically work shifts at Bristol today), but they were accessible and invested in other ways. They made me feel perhaps for the first time that I was a part of something, and not just working for someone else.

This connectedness and involvement gave new meaning to working shifts, attending department meetings, to peer review meetings (I am now a peer review chairman), and to other projects, such as community outreach programs. Of course they implemented processes, eliminated roadblocks, and instituted other programs to help improve Bristol Hospital. But all of a sudden, I was part of a bigger cause, and it sincerely gave additional meaning to my work.

Many hospitals view ED physicians as replaceable or transient. Often times we are dictated to, told what to do, or just what we are doing wrong. MEP’s attitude, on the other hand, is one of constant and consistent improvement. Peer review meetings at MEP are an open, honest, and transparent process where providers can come together to talk about cases and work toward making ourselves better.

All told, five of the ED physicians who worked at Waterbury, including myself, ultimately moved to Bristol Hospital, and we are constantly reminding ourselves of the differences between the two environments. Each time we sit together at our workstations, where behind us is posted key quality metrics for every provider, we are reminded that at MEP we are being included and enlisted in helping our department work toward a higher standard.

And yet through all of this, MEP somehow manages to remain incredibly supportive and oriented toward ensuring its employees are happy and balanced in their family life. In some ways, it makes sense. That is MEP’s whole model – one big family, working together.

 - Rob Murray, MD

Inspiration, information and innovation all embody one of the biggest health informatics conferences in the world: HIMSS 2013. Having just returned from my first trip to the annual Healthcare Information and Management System Services (HIMSS) conference, I want to share my experience and absolute excitement for the future of healthcare information technology.

Approximately 37,032 people converged on New Orleans to explore all facets of healthcare IT during the conference, from politics to education. Over 900 exhibitors covered an overwhelming linear mile of convention center floor pushing wares and giving away everything from iPad Minis to jet skis (yes, jet skis). CEOs, CIOs, CMIOs, clinicians, informaticists and the industry’s leading representatives were present to share from around the globe. Keynote speakers included health system executives,  author Eric Topol, President Bill Clinton, and Karl Rove. It was a high energy, exciting environment that fostered exchange of ideas, high level networking and announcements of major innovations.

There were two major announcements I want to share, as they profoundly impact the way we will practice medicine over the next 5-10 years. The first was the opening of the HIMSS Innovation Center in Cleveland, OH in October 2013. HIMSS will use the 12,500 sq ft of space and invite all healthcare IT vendors to work together to achieve the highest level of interoperability.

I was able to demo the early results of this major interoperability movement at the HIMSS showcase. I was given a fictional patient and watched how the patient’s data was moved from the ED EHR to the PACS to pharmacy to outpatient EHR and home monitoring devices seamlessly and regardless of vendor hardware/software solution. MEP providers have been able to appreciate the benefits of Maryland’s Health Information Exchange through the use of CRISP. As a result of the HIMSS interoperability initiative in Cleveland there will hopefully be no place for patient data to hide or be excluded from access ever again.

The second announcement was the formation of the CommonWell Alliance. This non-for-profit trade association has a vision for making patient data available to all providers and patients regardless of where care occurs. They will work toward a national infrastructure to achieve patient linking/matching, patient access/consent management and record locator services. The companies that are already dedicating their time and resources to this important initiative include Allscripts, Athenahealth, Cerner, McKesson, Greenway and Relay Health.

I also want to share some key points, future vision and food for thought regarding healthcare IT discussed during Dr. Topol’s keynote speech. His initial discussion began with the healthcare industry lagging behind both airline and banking industries in standards and interoperability. Both of these industries function in a global theater that allows customers to enter/exchange data regardless of location.

Power to the customer: the airline industry has achieved the ability to handle double the passengers with half the staff at the exact same cost per rider over the past 10 years by giving customers the ability to manage their own data/baggage, etc. Home monitoring technology and the advent of smart phone technology could replace expensive in-hospital testing such as sleep studies where a pulse/oximeter could be connected to an iPhone for thousands of dollars in savings.

Digital voice technology to detect Parkinson’s earlier than ever before, breath tests for cancers and a mini-ultrasound in the pocket of every medical student (Mount Sinai) is the present and future of healthcare. This is merely the surface of the innovative technologies heading for medicine all with the goal of cost-containment and patient safety.

Finally, there is the incredibly exciting field of genomics. As clinicians we hear about genome projects, new cancer drugs and ways to diagnose all the time. I only recently learned about Translational Bioinformatics and personalized medicine from my graduate IT courses. Dr. Topol discussed the potential astronomical health savings from a genomics and personalized medicine. There are many Genomewide Association Studies (GWAS) taking place right now that will help us tailor not just cancer treatment but everything from the efficacy of certain medicines, to cures for diabetes, heart disease or stroke.

The future of Health IT and these many initiatives will be a part of the solution to many of today’s systems problems. Every keynote, vendor and political pundit discussed cost-containment, patient-safety and how we can achieve this through interoperability and giving patients the power to access/manage their own private health record. MEP shares this vision for cost-containment, quality and success – I will keep you all updated as our industry rapidly changes over the next few years.

- Jason Giffi, DO

“We have a mindset and culture to try to make our emergency department the best in Connecticut,” MEP’s own Dr. Craig Mittleman told the newspaper. “It’s about working together to create an environment where patients don’t have long waits and they get the highest quality of care.”

We encourage everyone to read and share the story here: In Good Hands – The Bristol Press

And congratulations to our amazing team at Bristol Hospital!