Friday, January 23, 2015
8 states seek to speed cross-state licensing
Eight states, Iowa, Minnesota, Nebraska, South Dakota, Texas, Utah, Vermont, and Wyoming, have introduced legislation that could speed the process of issuing licenses for physicians who want to practice in multiple states.
The Interstate Medical Licensure Compact would modernize and streamline interstate licensing while maintaining oversight, accountability and patient protections, according to the creator of the model legislation, the Federation of State Medical Boards (FSMB). The new interstate compact system would help physicians improve access to care for patients in multiple jurisdictions and help underserved populations receive the healthcare they need.
“The Interstate Medical Licensure Compact, which is now being considered in state legislatures across the country, offers an effective solution to the question of how best to balance patient safety and quality care with the needs of a growing and changing health care market,” said Humayun J. Chaudhry, DO, MACP, president and CEO of FSMB. “We're pleased to have supported the state medical board community as it developed this groundbreaking model legislation and look forward to working with states that wish to implement this innovative approach to licensure.”
The final model Interstate Medical Licensure Compact legislation was released in September 2014. Since then, more than 25 medical and osteopathic boards have publicly expressed support for the Compact.
“The growing number of introductions in state legislatures represents the desire for a dynamic system of expedited licensure that simultaneously respects the inherent role of state regulatory agencies in protecting the public,” added Dr. Chaudhry. “At a time when some within the telemedicine industry seek to implement licensing frameworks that undermine and circumvent state licensing rules and practice requirements, the Compact is a key element to ensuring state sovereignty while providing the license portability necessary to enhance the delivery of health care.”
The Federation of State Medical Boards (FSMB) has launched a new webpage and interactive map to track the progress of the Compact in state legislatures, as well as answer compact-related questions where individuals can see if their state has introduced legislation supporting the Compact.
3 highly effective ways to reduce readmissions
The enormous push continues to reduce readmissions, due in no small part to stiff financial penalties from CMS for the worst performing hospitals. The most commonly cited statistic is that about 1 in 5, or 20 percent, of Medicare patients are readmitted within 30 days. A staggeringly high number when you think about it. Having discharged thousands of patients and seen the characteristics of those patients that are frequently readmitted (who are unfortunately called “frequent flyers” in hospital circles), here are my 3 ways to help solve the problem:
1. Focused targeting
When we talk about readmissions, the first step is to identify those patients who are at the highest risk of coming straight back into the hospital. It's a mix of socioeconomic status, demographics, social support, education, and most importantly baseline co-morbidities and functional status. If your readmission program targets “everyone”, it will expend too much energy on the vast majority of people who don't get readmitted. Employing Pareto's principle (see my previous article); remember that 80% or more readmissions will come from 20% or less of the same patients.
2. Discharge process
Discharging a patient in the typical rushed environment of a hospital is too often haphazard and disjointed. This is the one chance to make sure that all the paperwork and instructions are as thorough and comprehensive as possible. Exhaustively educate the patient and family. It should be the physician that leads this process. Much is made of a discharge taking at least 30 minutes—but perhaps even an hour would be a better time.
The problem with this? It's not as simple as it sounds. In the real word of economic pressures for both doctors and hospitals, spending an hour with every patient you discharge isn't really possible (that's not just a problem for U.S. medicine, because socialized countries in fact usually see more patients in even less time).
3. Intense primary care
Studies may show differing results, but I can tell you with certainty that patients with strong primary care follow-up and outpatient monitoring are definitely less likely to be readmitted. Make sure those high-risk patients have close follow-up ideally within a day or two of exiting the hospital.
The drive to reduce readmissions is a noble one. But we have to be realistic too. With an ageing population, this issue is going to remain at the forefront. The nature of illness is that it's a fragile time for our patients, and particularly for those with chronic underlying illnesses such as COPD or congestive heart failure. It doesn't take much to push things over the edge and for people to be sick enough to require a hospital bed. Battling nature can be hard. The question is: how can we best minimize the likelihood of the next setback and continue to keep more and more people out of hospital and in the comforts of their own home?
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Thursday, January 22, 2015
An update on flu season
This year's flu season has started earlier than expected and has already reached high numbers of flu cases in 36 states. California is not one of them, but that likely means we're a couple of weeks behind the East Coast, not that we'll be spared. In fact, this week I saw my first patient of the season who had a positive test for the flu, and Google Flu Trends suggests that the numbers of cases in Los Angeles just started to increase.
It's too early to know whether this season will be worse than previous years. That largely depends on how soon the disease peaks and then declines. But this season has already caused more hospitalizations than usual and a large number of deaths. As of December 20, 18 children have died of the flu.
Part of the reason for this season's intensity is that the predominant virus strain circulating is H3N2, a strain that usually causes more hospitalization and deaths. To make matters worse, though this year's vaccine includes the H3N2 strain, the virus has changed since the vaccine was made, making the vaccine an imperfect match for the circulating virus. Still, an imperfect match is better than none, and health officials still urge everyone over 6 months of age to get vaccinated. Remember, if you're young and healthy getting the shot isn't primarily about protecting yourself. It's about making it less likely that you'll transmit flu to a more vulnerable person that you come into contact with.
Please take a moment to review the Centers for Disease Control and Prevention's (CDC) advice about what to do if you get the flu. It has a helpful summary of flu symptoms and treatment, as well as warning signs of severe illness. If you have a mild illness, please stay home. If you have severe illness or are at high risk of developing complications contact your doctor immediately. Antiviral medication works best if taken in the first 48 hours after the onset of symptoms. Let's also all do our best to cover coughs and wash our hands frequently.
I wish you a happy and healthy year. Let's hope this flu season peaks soon and that your first achievement of 2015 isn't getting sick.
Severe Flu Cases on the Rise in U.S. (Wall Street Journal)
This season's flu activity has reached the epidemic threshold, the CDC says (The Washington Post)
Teen's death shows horror of flu epidemic (CNN)
Google Flu Trends for Los Angeles
The Flu: What to do if you get sick (CDC)
Weekly US Influenza Surveillance Report (CDC)
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
Does quality of colonoscopy depend on time of day?
Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.
The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical quality is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher “quality” colonoscopies, will patients actually benefit? We don't know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?
An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven't looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he'll get scheduled accordingly.
I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.
The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?
Here are some studies I propose, which can be funded in our government's usual manner: borrow.
Profession vs. Quality Measurement per Shift Hour
Policeman vs. Arrest Record
Thief vs. Successful Robberies
Financial Advisor vs. Profitable Advice
Politician vs. Promises Kept
Stage Actor vs. Lines forgotten
Judge vs. Decisions Reversed
Since pay-for-performance is the panacea that will cure the medical profession, why shouldn't we share it with the rest of you?
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Send comments to ACP Internist staff at firstname.lastname@example.org.
- 8 states seek to speed cross-state licensing
- 3 highly effective ways to reduce readmissions
- An update on flu season
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.