ICD-10 is coming…

As I write this, the ICD-10 Countdown Clock on the CMS website reads 54 Days, 14 Hours, 22 Minutes, and 13 Seconds (no, 8 Seconds, 5…). The fact that this clock exists gives you some idea of the import of this transition and the anxiety it is provoking. ICD-10 refers to the International Classification of Disease, tenth edition, published by the World Health Organization (WHO). ICD-9 has been in use since January, 1979. WHO started work on ICD-10 in 1983, but did not finish until 1992. Other countries started implementing it in the late ‘90s. In fact, the United States is one of the few developed countries that has not yet made the transition. We made the change from ICD-9 for coding and classifying mortality data from death certificates in 1999. The Department of Health and Human Services proposed in 2008 that we begin using ICD-10-CM, the Clinical Modification and ICD-10-PCS, the Procedural Coding System, for reporting. The recommendation became rule with an implementation date of October 2013. That got pushed back twice, and now we are finally staring down the drop-dead date of October 1, 2015.

Hopefully, your preparations to manage the transition are well underway. If not, CMS suggests the following steps: talk with your practice management vendor; be sure systems have been upgraded to the 5010 standards; discuss implementation with billing services and payers, including discussing with payers if contracts are affected; identify necessary changes in workflow and address staff training needs; conduct test transactions in advance of the October 1 deadline to be sure they are successfully received.  [CMS ICD-10 Basics]

ACP provides resources to address the ICD-10 transition: check them out here.

 

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Chapter Member Spotlight: Chris Sankey

Here is another installment in our continuing series highlighting Connecticut Chapter members who have been involved with ACP at the national level. Christopher B. Sankey, MD, FACP is an Assistant Professor of Medicine and academic hospitalist at Yale University. He is the Physician Editor for The Brief Case, a clinical vignette series that appears in ACP Hospitalist.  Dr. Sankey writes:

“One of my greatest clinical interests to date has been the development of clinical vignettes and mentorship of students and residents in this process. In true “friend-of-a-friend” fashion, I discovered that ACP Hospitalist was looking to develop a section in their publication devoted to clinical vignettes. In speaking with Jamie Newman at Mayo, we decided to have me helm this new section, entitled “The Brief Case”. The Brief Case comes out in ACPH every other month, and typically features an “installment” (5-6 cases) from a medical center or hospitalist group (usually an academic center), along with an individually-submitted case (usually a community-based provider). The goal of the Brief Case is to give clinical pearls that are relevant to the practicing inpatient provider.

The Brief Case has been a great success. We have had a tremendous interest from institutions and individuals alike; the volume became so substantial that I enlisted the assistance of recent Yale IM grad and current Montefiore Hospitalist Jamie Galen to be my deputy editor.”

Dr. Sankey will be featured at our Annual Chapter Meeting on October 30; he will be presenting a workshop called “Case Writing for the Busy Clinician: Opportunities and Obstacles.”  This interactive workshop will provide “hands-on” experience. Activities will be aimed at all levels of training and prior experience with case writing. The goals of the workshop are to identify essential elements of a case, overcome common obstacles, identify the appropriate type and venue for submission, and assist attendees in the preparation of an outline of a draft for submission. Dr. Sankey will share his own experience, ranging from how he published his first clinical vignette to his experiences as an editor, in order to guide participants on a relevant, practical path towards a successful case write-up and submission. Pearls will be highlighted to help improve the likelihood of a fruitful submission.

The latest installment of The Brief Case can be seen in the July issue of ACP Hospitalist.

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Restoring the Narrative

This year, the Board of Governors is taking up the theme of “Restoring the Narrative” to medical note-writing. I think most of us recognize adoption of the EHR as a factor accelerating the loss of narrative, although this process was already well underway. In fact, the time pressures placed on clinicians have probably done as much, or more, to erode the narrative from the medical record. But templated EHR documentation, with its discrete inputs and generic presentation, has effectively buried the narrative. If we hope to improve patient care through better communication, restoring narrative will be an important factor. Eliminating extraneous content to truly achieve EHR use that is meaningful (as opposed to Meaningful Use) should be an objective worth striving for.

A related theme is that of the patient’s voice. In addition to the factors mentioned above, the rise of data has also inadvertently minimized the patient’s voice in construction of the medical history. As Bradby et al state: “There is no suggestion that medical professionals intend to disregard patients’ narratives or to deem them inadmissible to clinical decision-making, particularly given that medical students continue to be taught to listen to their patients. Rather, the epistemology of epidemiologically-informed, statistically significant evidence that underpins the interpretation of results from tests and assays trumps the nature of patients’ stories as a form of knowledge at almost every turn.”(1)

Every day, we encounter and try to reconstruct patient stories. Communicating these stories in a manner that is more pertinent and relevant will lead to better patient care. I welcome your comments about “Restoring the Narrative”!

1) Bradby H, Hargreaves J, Robson M. Story in health and social care. Health Care Anal. 2009 Dec;17(4):331-44.

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Supreme Court Upholds Subsidies in King v. Burwell Ruling

On Thursday, the Supreme Court handed down its long-awaited ruling in the King v. Burwell case.  At issue was whether or not the IRS could continue to extend tax-credit subsidies for health coverage purchased through exchanges established by the federal government under the Patient Protection and Affordable Care Act (because the legislation specified state-run exchanges only).  Had the Court ruled the other way, the ACA would have been seriously threatened, as 34 states have federally-run exchanges.  Connecticut would not have been affected directly, because we have a state-run health insurance marketplace.  But nationwide, over 6 million people would have lost tax credits in excess of 1.7 million dollars; on average across these states, premiums would have climbed close to 3-fold.

The legal decision, with Chief Justice Roberts writing for the 6-3 majority, turned on semantics and interpretation of the language of the ACA.  What did Congress intend?  Would they really want to withhold subsidies where states refused to set up their own exchanges, and federal marketplaces were required?  To what end – to punish the states?  The plaintiffs had an implausible story: that Congress intended only state exchanges, not a federal exchange, to receive subsidies in an effort to strong-arm the states into creating them.   The minority objectors (Scalia, Alito, Thomas) derided the loss of the meaning of language in a shrill response:  “Words no longer have meaning,” Scalia wrote, “if an Exchange that is not established by a State is ‘established by the State’.”  Justice Scalia would look to abandon common sense, as if Congress meant to undo everything the law was established to create in the first place, if only someone could find a linguistic technicality and bring it to light.

Thankfully, common sense prevailed on Thursday.

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IM 2015 – ACP’s Centennial

ACP just concluded its annual meeting and it was outstanding!  First, it was great to see so many CT Chapter members at the meeting.  It is a particular treat, for a program director, to see former trainees who are thriving in their practices and lives.  The annual meeting serves as a great opportunity for impromptu reunions.

The scientific offerings were superb.  The quality of the all of the sessions I attended was high; I learned about a wide variety of topics from medical care of the pregnant patient to health IT to medical history.  As always, the Thieves’ Market was very entertaining.  The annual meeting also provides an opportunity to get involved; next year, consider volunteering to review resident or student abstracts before the meeting or serve as a poster judge during the meeting – this can be very rewarding!  I had the chance to provide judging for one of the Doctors’ Dilemma rounds this year.  There was tense action with young women and men displaying very impressive rapid recall of knowledge.  Our CT Chapter champions, Yale University, fought valiantly but bowed out in the first round.

The Centennial Celebration also provided the opportunity to look back at what some very talented and dedicated internal medicine physicians have helped accomplish in advancing the state of the science and policy of health care.  We have the obligation to continue that work and push internal medicine further across the next century!

Congratulations to our marching Fellows: Francis Amoo, Steven Angelo, Catherine Arnold, Patrick Asiedu, Michael Ayepah, Pia Dogbey, Sujata Kale, Joseph Kittah, Sherry Kroll, Elizabeth Ofori-Mante, Onyema Ogbuagu, Olubunmi Otolorin, Lynne Savino, Alfred Vichot and Benjamin Yeboah.

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Introducing Chapter Members on National Committees: Julie Rosenbaum

As I have mentioned before, we have several members serving on national committees for the College, and I wanted to introduce you to what they are up to.  Julie Rosenbaum, MD, FACP, who is a faculty member of the Yale-New Haven Medical Center (Primary Care) Program, sits on the ACP Ethics, Professionalism, and Human Rights Committee.  Dr. Rosenbaum writes:

“Since April of 2014, I have had the honor of serving on the APC Ethics, Professionalism, and Human Rights Committee (EPHRC). Because of my long standing interest in medical ethics, I had often read the statements from this committee in Annals of Internal Medicine over the years. These have included such topics as online professionalism, physician-assisted suicide, and physician-industry relations. This is the committee which updates the American College of Physicians Ethics Manual, which is currently in its Sixth Edition.

The official charge of the committee is “to formulate principles and policies in ethics, professionalism, and human rights for the Board of Regents, uphold high ethical standards in medicine, and advise ACP’s Ethics and Professionalism staff.” The committee includes a Chair, who is a Regent of ACP, a Vice-Chair, who is a Governor and 10 additional members who include at least one Regent, at least one Governor, one Resident/Fellow member, one Medical Student, and one Early Career Physician member. Members are appointed for one year terms, renewable up to three times, and therefore a total term of four years. The Committee meets in Philadelphia two times a year, usually once in June and once in the fall. There is often a separate committee conference call in February and a brief meeting during the ACP Annual meeting.

The meetings occur in the Boardroom of ACP and are supported by an outstanding staff, led by Lois Snyder Sulmasy, JD, who is an expert in clinical ethics and health policy. Lois has been at ACP for several years and has incredible institutional memory and understanding of how the EPHRC works with other committees and supports the efforts of ACP generally.

During recent meetings, the committee has considered how to formulate ACP recommendations regarding direct payment practices with the Medical Practice and Quality Committee. We have discussed the novel ethical implications of electronic health record in conjunction with the Medical Informatics Committee. At each meeting, we receive updates from the Board of Governors and Board of Regents, whether about the recent Maintenance of Certification controversy or resolutions on how to disseminate information on gun safety to members of the ACP.

Participating in this committee has given me a new appreciation for the efforts of the ACP to advocate on behalf of physicians and our patients, and how a large organization works to advance its mission and uphold its standards. The meetings themselves are fascinating opportunities to consider the ethical issues of our day with like-minded colleagues from around the country, examine multiple aspects of difficult issues, and formulate clear responses and positions for ACP. I will have the honor of helping to present the Update in Ethics Issues at the ACP Annual Meeting in Boston in April. Hope to see you there!”

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The Connecticut Choosing Wisely Summit

I just returned from attending the first Connecticut Choosing Wisely Summit – an excellent meeting.  If you are not already aware, Choosing Wisely is an initiative of the ABIM Foundation to promote the selection of care that is supported by evidence and truly necessary.  It should be pointed out that the National Physicians Alliance pioneered this movement by creating lists of things primary care physicians could do in their practices to foster practical use of resources.  Today’s event was hosted by the CT Choosing Wisely Collaborative and held at the Frank H. Netter MD School of Medicine of Quinnipiac University.  We first heard from Dominic Lorusso, Director of Health Partnerships for Consumer Reports (one of the primary groups partnering with the ABIM Foundation in the Choosing Wisely initiative).  He noted that since the initiative began in 2012, the number of partners has grown from 11 to 65.  There are now 67 specialty society lists of “Five Things Physicians and Patients Should Question” as well as 74 “two-pager” monographs aimed at educating patients (check out the lists at http://www.choosingwisely.org/doctor-patient-lists/).  Lorusso described their use of Wikipedia, embedding information and links to the Choosing Wisely monographs (for example, look up “sinusitis” on Wikipedia and scan the references).  He introduced the list of general questions they are promoting: 5 questions to ask your doctor before you get any test, treatment or procedure:

  1. Do I really need this test or procedure?
  2. What are the risks?
  3. Are there simpler, safer options?
  4. What happens if I don’t do anything?
  5. How much does it cost?

As you can see, this basically constitutes elements of shared decision making, which we should be prepared to discuss anyway – although admittedly the fifth question, about the cost, can be challenging to answer.  If you haven’t already seen Healthcare Bluebook, check it out; it can give you a starting point about price (even if that doesn’t represent what your patient will have to pay).

We then heard from Jasmine Dupont, JD, of Maine Quality Counts.  She talked about how her group engages consumers about health care by using Choosing Wisely.  She described how they selected 8 focus areas that they are encouraging providers to limit, drawn from the Choosing Wisely lists:

  1. Cardiac imaging for patients at low risk for heart disease
  2. Imaging tests for low back pain
  3. Antibiotics for upper respiratory infections
  4. Imaging tests for uncomplicated headaches
  5. Bone-density scans for low-risk women
  6. Sleeping pills or sedatives for insomnia, agitation, or delirium in older adults
  7. Opioids or butalbital as pain medications for treating migraine headaches
  8. Imaging tests of the head in emergency department for minor head injuries.

One of the highlights was the presentation by the group from Vanderbilt University.  Donald Brady, Senior Associate Dean for GME, described their institution’s resident-led, leader-supported initiative around Choosing Wisely.  They formed the House Staff Choosing Wisely Steering Committee (about which you can read more here).  Two resident leaders, Wade Iams (Internal Medicine) and Josh Heck (Radiology), described the program.  Residents selected an area of focus they were very familiar with – daily labs for hospitalized patients – and developed a plan to reduce use.  They partnered with others in the institution to create a dashboard reporting use and estimates of what was avoided by limiting use: such as how many unnecessary labs were eliminated, how much blood not drawn, and how many misleading results avoided.  An intensive education campaign, and some friendly competition, helped their initiative to succeed.

Breakout groups gave an opportunity to discuss ideas for implementation here at home.  There were groups for Communities and Consumers, Health Professionals, Health Systems, Point of Care and Workplace.  We discussed how prompts built into EMRs could be helpful and how integrating with the SIM project could give Choosing Wisely a lot of visibility in Connecticut.

I want to remind you that the ACP, as well as contributing its own list to Choosing Wisely, launched the complementary High Value Care initiative.  This includes a toolkit to help facilitate patient-centered communication in the referral process, between primary care and subspecialist doctors; a curriculum for educating residents; and the online cases, which provide free CME and MOC credit.  I would like to encourage you to incorporate High Value Care and Choosing Wisely into your practice.

-Rob Nardino

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