Emergency Provider Documentation

1. Emergency Provider Documentation Prepared by: Dr. Hal Watz Chief Compliance and Medical Officer

2. Quality? / Quality! Are we Improving Outcomes?

3. Quality? Value=Quality/Cost Since this is an equation we can multiple both sides by Cost and we get Cost*Value=Quality So if I keep Value constant then every time I increase Cost I increase Quality. This does not seem to be correct.

4. Quality? Surviving Sepsis Campaign 2004 Activated protein C –Xigris, now withdrawn from the market. Dopamine first choice for shock not responsive to fluids, now NE. Tight glucose control(<150mg/dl), now (<180 mg/dl) Transfuse to maintain a HGB >10 g/dl, now 7-9. Resuscitation based on serial central venous O2 sats. Found to not provided any survival benefit and were very expensive.

5. Quality? Given all the parts of the bundle that we got wrong how is it possible that the mortality rates for sepsis have dropped markedly? The focus on sepsis has dramatically increased the number of patient who are being diagnosis with sepsis. This includes the low risk ones who might be the SIRS patients (systemic inflammatory response syndrome). The increased awareness and use of lactate levels have gotten us to using antibiotics sooner and rehydrating 30 ml/kg. This volume of rehydration is being questioned. In medicine when you think you know something wait and it might change.

6. Quality! MACRA is all about increasing quality and not increasing cost. How do we go about decreasing cost? Will ACOs be the answer? The Medicare Trust Fund is now scheduled to be bankrupt in 2029 but will still receive some funds every year so will need to be supplemented. Which means some other part of the government services will not be funded or we just borrow more. Why does the government prevent Medicare from buying Canadian pharmaceuticals?

7. Quality! According to a 2017 study by Deloitte only 30% of an individuals health and well being is address by conventional medical issues and treatments. The other 70% is determined by “Social Determinates of Health” (SDoH). “food insecurity” “fall risks” “social isolation in the elderly” “affordable housing” “availability of healthcare”, “transportation”

8. Communication These are outside of what a provider can effect. These need to be address by “Creating a Connected Community”. The Problem is our disconnected solutions. EMS, Meals on Wheels, Soup Kitchens, Churches, Shelters, Mental Health Clinics, EDs etc. Each helping but individuals fall through the cracks. Often times the people end up at the most expensive alternative. Solution: A connected community.

9. SDoH Connect Public, Private and Charitable Agencies. Based on issues, tasks and networks. Issue- something that needs to be addressed Task- something that needs to be done. Network- Community-wide care teams. Depending on the issue or task each network can be different.

10. Example: Fall Risk Patient is suspected of being a fall risk while in the ED for another healthcare related complaint. Case management is asked to be involved and with the patient’s permission a request for “Fall risk assessment” is sent out over the network and one of the hospital’s partnering organization accepts the request and sees the patient the following day. Cost of a hip Fx ($39,500).

11. Network Build a focused network- opioid addiction network. Behavioral health clinics EDs PCPs These are all tied together through one system that notifies the other members as needed. Pt. comes to the ED notice is sent to the Behavioral health clinic who contacts the patient

12. We have this solution in Colorado Springs. We have been using it for over 18 months. This is run through our Fire Department’s EMS system. As you know a small % of our patients/population spend a large % of our healthcare dollars. We have teams that are sent out to try to prevent transports to the ED. Paramedics and mental health workers since our most at risk population are those with mental illnesses. We have seen a significant decrease in ED use from this population.