Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

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“Daddy, I want an iPad.”  This is a common request heard by parents, but this one was coming from my daughter in medical school, who already possessed a MacBook and an iPhone!  Just beginning her clinical rotations in her third year, she noticed many of her peers using iPads to look up questions they had on a medication, the pathophysiology of the disease the attending was lecturing on at the moment, or even to study a lecture or required reading.

It is no secret that physicians have flocked towards the iPad for both work and play, with multiple surveys showing high penetration rates in this demographic.  Mobile technology is clearly overtaking healthcare with the term “mHealth” achieving buzzword status.  But, is the tablet the right tool for the job?

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8/21/2012 8:06:44 PM | 1 comments

In John Commins’ article, Value of Rural Hospitals Linked to ED Utilization, he points out that the rural healthcare environment is vastly different from urban areas. He cites some very poignant reasons for these differences, including that rural hospitals do not enjoy the same economies of scale and leverage with vendors and insurance companies. Commins says that while rural hospitals are perceived to deliver a lower level of care than is provided in urban areas, he thinks this perception is incorrect. I would take this point one step further. I believe that, overall, the financial and operational efficiencies of rural EDs provide an insight into the model of how to survive in the new healthcare economy .

Ironically, rural EDs have become a blueprint for maximizing efficiency because of their lack of resources. Rural EDs are forced to optimize their efficiency, mostly because of the way they are reimbursed. In California, for example, rural EDs primarily have self pay and Medi-Cal payers. This reimbursement is much less than the PPO and HMO payers that support urban centers. This payment demographic forces rural EDs to be more efficient. There is an understanding by providers in rural California that they must see more patients per hour than their urban counterparts have to see, just to avoid going out of business.

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8/17/2012 10:08:37 PM | 1 comments

Which Hospital-Based Physician Specialty Will Wield The Mightiest Pen In The Future?

In my last two blogs I examined how the dynamic behind bundled payments will create a vacuum to be filled by those with the most leverage. The leverage wielded by any physician specialty group will be determined not only by its ability to generate the most revenue and to save the most money, but also by the size of its integrated group.  And as CMS puts greater emphasis on hospital-acquired infections and readmission rates, I believe we will see the hospitalist emerge as the hospital-based physician specialty that holds the most leverage within the hospital in the new healthcare environment.

In the past, hospitalists have been on the lower end of average compensation for all hospital-based physicians, but that can be expected to change significantly in the future. Although they are a relatively new specialty compared to their colleagues, the growing leverage of the hospital medicine physician within the hospital may soon overshadow that of the other, more-established hospital-based physicians. Their importance to the financial performance of the hospital continues to become more apparent with new compensation methods being promoted by both commercial and public payers. 

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8/14/2012 5:13:24 PM | 0 comments

With rising health care costs, declining reimbursements, and increasing numbers of uninsured and underinsured, hospital CEOs face ever growing challenges to meet their narrowing margins. In addition, local and state officials are attempting to meet their budgets in the face of exploding Medicaid expenses, while the federal government is dealing with the fact that Medicare could go bankrupt in a few years. Needless to say, the stress level in this country regarding medical care is very high.  This is a bit disconcerting, as people rarely make good decisions while under stress.

That said, these are very exciting times, even historic times, and we are right in the middle of them (or at least we should be).  The Affordable Care Act has generated a lot of angst and everyone is trying to position themselves to succeed in this, soon to be, new reality.  Just look at the ACOs, the bundled payments, the medical homes, and the government think tanks (boy there is an oxymoron).  The healthcare landscape is like a land grab, and you will only be included if you can prove that you are useful (and cheap).  As ED physicians, we are at a disadvantage as more focus is being placed on the outpatient area.  On top of that, we are seen as being a big part of the problem, because of ED over-utilization by patients (never mind that the ED only accounts for a very small amount of health care dollars).
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8/10/2012 4:32:12 PM | 0 comments

As we continue in our Lean journey, much of what we are experiencing and learning so far relates to the methods of Lean, such as the vocabulary and multi-day improvement events. It's now time to develop further expertise with an equally important aspect of Lean: The Lean mindset.  The Lean mindset refers to an underlying focus on continuous improvement and problem-solving. The great news is that the method of problem solving is similar to what you  already use during a standard patient evaluation.  After reading my blog and reviewing the table below, I hope this is clear enough to apply to a problem you're having in your ED.

First, I would like to introduce another Lean term-- The Improvement Kata.  Kata is the Japanese term for routine. In Lean, the routine, or kata, we aim to repeat involves constantly defining new target conditions, or desired states, then using problem solving and PDCA (plan-do-check-act) in short cycles to get there.

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8/7/2012 8:14:05 PM | 1 comments
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