Archive for category Informatics
Provided by Barbara K. Tomar, ACEP’s Federal Affairs Director
The Medicare Access and CHIP Reauthorization Act (MACRA) Final Regulation was released Oct. 14. This rule – now designated by CMS as the “Quality Payment Program”- describes requirements for physicians to participate in the Merit-based Incentive Payment System (MIPS) and/or the Advanced Alternative Payment Models (Advanced APMs). Both begin January 1, 2017.
Former ACEP President Dr. Mike Gerardi appointed an APM Task Force that is developing some models that we hope will be reviewed and approved by CMS over the next year. Work of the Task Force was overseen this past year by Immediate Past President Dr. Jay Kaplan and current ACEP President Dr. Becky Parker has pledged to continue to support Task Force efforts.
It’s important to note that since few emergency physician groups have ever participated in various CMS bundled payment models/ACOs, etc. in the past, we expect most of the members to participate in MIPS for the next year or so.
We were pleasantly surprised in our early review of the 2,200-page rule, that CMS responded to ACEP’s comments on the timing and scope of some of the new programs.
Merit-based Incentive Payment System (MIPS):
- Reduces timeframe for reporting. Instead of reporting quality measures (much like PQRS) for a full calendar year starting in January, members can report for as little as 90 days of their choosing and avoid the 4% penalty in 2019. (Similar to PQRS, there will be a 2-year lag between data reporting imposition of bonus/penalty.)
- Doctors can report MIPS as individuals or through their groups. However, physicians must elect one or the other for all MIPS categories.
- Quality measures reporting reduced from 9 to 6. Either 6 measures or a specialty measure set can be selected, 1 of which must be an outcome measure; if no outcome measures are available, a high priority measure.
- Reporting thresholds reduced from 90% of patients (or 80% for claims reporting) to 50% in 2017.
- Encourages the use of QCDRs and electronic sources through preferential scoring.
- Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the (requested) reduction of the cost performance category weight to zero next year. CMS was going to weight ‘resource use’ at 10% – a nearly impossible measure for EM due to current cost attribution methodology.
- CMS working on patient condition and patient relationship codes to improve future cost attribution. (ACEP’s recent comment letter to CMS noted that none of the patient relationship codes fit EM practice so we will continue to work with CMS to change this).
- (Clinical) Improvement Activities reporting burden reduced. Highly-weighted activities (20 points) reduced from 3 to 2 and medium-weighted activities or some combination of both need to equal 40 points. (Use of QCDR is highly weighted).
- Allows 90-day reporting, also.
- Advancing Care Information (previously known as Meaningful Use) reporting reduced.
- EM has been exempt from reporting on EHR measures and may continue to be in spite of the burden placed by the hospitals.
- Also reduced to 90-day reporting for 2017-2018
Advanced Alternative Payment Models (APM):
- Reduces amount of losses that APMs must bear. CMS used the term “more than nominal risk” in the draft and proposed that qualified APMs pay of to 4% of Medicare spending. The final rule is based on physician/APM revenue which would be at risk for 5% of revenue losses instead.
- Expanded the definition to include practitioners other than physicians so that models can address quality and costs of non-physician services.
Physician-focused payment model Technical Advisory Committee (PTAC):
Note: This brief description of PTAC is included as background as no changes to its role were made in the final rule.
- MACRA created the PTAC (of outside experts) to assist physician groups who are creating APMs, providing a first line review of proposals to determine whether such proposed models meet the criteria established by the Secretary of HHS for PFPMs and offering some technical assistance. Based on its findings, PTAC can make recommendations to CMS as to whether the model should be refined, further studied, tested or implemented, but CMS makes the final decision through its own application process.
The internet has fundamentally changed the way we understand and interact with the world: not just as physicians, but in our daily lives; however medicine (especially academic medicine) still lives in the dark ages. The ways of old are starting to show signs of wear, that this is beginning to change. And as things in the age of information move at an ever more-rapid pace, I think the changes will be here before we know it. I, for one, welcome our new data overlords.
The medical journal was initially created as a forum: a way to publicly share information with your colleagues, and get credit for the discovery. Say you wanted to tell the world of a new surgical technique. Or a new drug that you’ve discovered to help your patients. You could discuss it with a few colleagues in the hospital. But if you think you’re really onto something — something that really might be great and really might help not just your patients, but everyone’s — you’ve got to spread the word. And that’s how the journals started. Not with research, but with physician opinions and approaches and case reports and “Hey look what I found out”s. If you go back to the early publications of the New England Journal of Medicine — which now allows you to search from their archives from 1812 on – you can see some pretty cool stuff. Punch in your favorite subject and you’re transported back in time to when physicians like you were still trying to figure out what the hell was going on with this patient, instead of the biochemical cytokine pathway of today. It’s pretty incredible.
So here’s my first point: look how we share information today (and honestly, we’re just getting started): Twitter, Facebook, emails, blogs, text messages, Google, Wikipedia. Sure sure, we still share some very important information through medical journals, but they simply can’t keep up. Hundreds of new medical journals are launched every year, for everyone’s own sub-sub-specialty out there. Yet the hunger for publication and knowledge continues to grow. Let’s just consider the case report, for example. Imagine you’re staffing a hospital in the late 70s/early 80s in New York, or San Francisco, or Los Angeles, and you find these small crops of patients with really, really weird infections. You scratch your head, dig in a little deeper, and publish what you’re finding in the New England Journal of Medicine in the December 10, 1981 edition. Four months later, several replies are published: it’s marijuana use; no no, it’s the amyl nitrates that the gay men are using; of course not, it’s the CMV they’ve been exposed to; no, you’re wrong, this is something entirely new we’ve never seen before. It’s an absolutely fascinating read of the natural course of HIV’s research pattern, but one that I imagine would be very different today (and will be different when the next HIV/AIDS-like disease hits):
Okay okay, so fine, that’s just case reports. And medicine and science and the scientific method evolved, and It Was Good, and then medical journals became the place to publish research. Big trials. Lots of money. Which brings me to my second, unforunate point: peer review is not all it’s cracked up to be. Some concerning data (ironically, yes, published in the journals):
- Association of Funding and Conclusions in Randomized Drug Trials, JAMA 2003: if your randomized trial was funded by Pharma, it was 5.3 times more likely to recommend the experimental drug than if it was funded by a non-profit organization.
- Undisclosed Changes in Outcomes in Randomized Controlled Trials: An Observational Study, Annals of Family Medicine, 2009: In 31% of randomized controlled trials, the primary outcome had been changed (without disclosure) after the trial had been submitted to the clinicaltrials.gov database.
- Females may be less likely to get papers accepted.
- When you blind reviewers to information about the author, they are less biased in their acceptance of abstracts.
Now, I’m not saying that peer review should be discarded, or that journals should cease to exist, or that we should throw the baby out with the bathwater. I am, saying, however, that I think there’s room for another option, using the internet, social networks, and crowdsourcing. (NB: In this topic I am building on existing ideas from Chris Nickson/LITFL’s Time to Publish Then Filter? and The Wisdom of Crown Review which also references these BMJ and Annals of EM opinion pieces.) I agree with Chris: I don’t know exactly what form this should take, but something like an academic Twitter (Trip Database’s TILT?) might not be a bad start. I hate to make this all a popularity contest (mostly because I lost those so vigorously in high school), but the cream typically rises to the top when something is put to the crowds. (But sadly, not always. Okay, at least, the academic crowds.)
Or perhaps it’s meta-reviews of the data. It’s online Critical Care Journal Clubs, or it’s a rating system to articles with ratings from colleagues you like and trust (and who know the literature better than you) like Leon Gussow’s 5/5 Skull and Crossbones at his Toxicology blog. Or podcasts reviewing a single topic. I’m not sure if it’s centralized. Who knows. Someone will build it and get it right (maybe me?) and we’ll go from there.
And all these great online links and resources lead me to my final point: “academic” works cannot and should not be limited to the length of one’s search in Pubmed as author. Yes yes, I’m suggesting the beginning of an academic new world order, and should be burned at the stake for such heresy (especially since I’m going into academics). But “publish or perish” should not simply mean “get your name in a journal.” Academics is the pursuit of knowledge, the pursuit of teaching and education. Case in point: Rob Reardon, narrator of so many of those fantastic ultrasound videos that I’m forever loving, is a well-published article in the journal world as well. But I guarantee you this: the amount of education that Rob has produced on his website — and that people have learned from — already exceeds the amount of whole-world educational impact of his Pubmed career. It’s simply exposure from the internet versus exposure through one journal.
Like-minded people (frequently education-minded, tech-oriented like myself) are doing this all over the web. They’re frequently (but not always) affiliated with some sort of academic place — be it an official medical school or simply an area where residents rotate — and do it because they enjoy it. And none of it would make it into a journal article. It’s too short, or too fast, or too digital, or simply too practical — but yet clearly useful. And it should be valid and appropriate academic work, recognized by our peers. (Let the crowds do the peer-reviewing of these publications if they like. Don’t like one of Rob’s videos, or disagree with him on something he says? Leave a comment or send a message on Twitter for all the world to see.)
There is a huge, huge volume of really high-quality learning on the web, especially in Emergency Medicine (much of which I’ve documented here), and it’s only becoming better.
Journals are here to stay — and I welcome them. They provide an important resource to develop and publish research and trials, and are still the biggest forum available to spread one’s medical ideas. But at the same time, there is content and ideas and a wealth of knowledge and information-sharing going on that is occuring not in sequence — but in parallel with them. Information that is simply out of the realm and scope of the journals and old-fashioned peer review. We are starting to develop the tools to share this information, and I look forward to where the next 10 years take us. (Hopefully to at least a modicum of technologic advancement in the snail’s pace at which medicine frequently changes.)
[vimeo width=”600″ height=”400″]http://www.vimeo.com/17939318[/vimeo]
Hey readers! Had a fantastic time at ACEP, and have been busily interviewing for fellowships and trying to update theNNT. We’re launching two new features today:
- The NNT Intervention Quiz is an attempt to blind you from your medication biases and just look at the data. We as a group took the test ourselves, and were pretty surprised at how we ranked medications when you don’t know their names–and we think you will be, too.
- And of course, the obligatory Facebook page.
We’re trying to make the site as useful for you, the practicing community and academic emergency physician. If you have suggestions for reviews you’d like to see, please let us know, and if you’d like to write a review, email us!
Sorry for the dearth of blogging as of late. I’ve been hard at work on my most recent web project, and we’re announcing it first on The Central Line!
It’s called The NNT, and it’s a great resource for both academic and community physicians alike. We’ve essentially tried to find the best evidence (frequently, but not always Cochrane Systematic Reviews) out there for a bunch of different interventions (mostly emergency medicine ones), and come up with a simple summary of how well (or how poorly) they work. We wanted the site to be an easily-accessible, one-stop shop for evidence and data on interventions we already know about. A couple examples:
- Systemic Steroids for Asthma Attacks work great. Give them to 8 asthmatics, and you’ll prevent one hospital admission.
- Did you know there’s really no good data supporting giving Proton Pump Inhibitors for Upper GI Bleeds? They maaaybe reduce how much patients get transfused by a half unit of blood, but have no effect on patient-important outcomes, like death, need for surgery, or re-bleeding.
- And glycoprotein IIb-IIIa inhibitors still haven’t shown a benefit, but they definitely increase major bleeding.
We hope the site encourages a lot of discussion — and maybe a little controversy — among you, your colleagues, your consultants, and your residents and medical students. We welcome your feedback and suggestions, and if you’re interested in writing a review, send us a message!
We all know how quickly things change in the ER. One minute you’re quietly browsing the Web, the next you’re running a code. Ironically, with all the chaos that surrounds our workplace, your laptop, iPhone, smartphone, iPad or other personal mobile device may actually be more at risk than your patients are.
All kinds of people move through the ER. Some are more than willing to commit crimes of opportunity. All it takes is for an expensive device to be left unattended for a moment and it can be gone. And despite what you might assume, not all homeowner policies cover the full value of stolen personal devices, especially ones used professionally.
It only gets worse. If somehow your device crashes to the floor and is rendered unusable, factory warranties won’t cover the repairs. Even supplemental policies, the kind offered by many retailers, exclude damage caused by full liquid submersion. (Before you ask where or how full submersion occurs, consider how many people carry cell phones and iPods in their shirt pocket wherever they go—including the bathroom.)
It wasn’t until all this was pointed out to me that I looked into the coverage for my devices. There were significant gaps. I became concerned that accidental damage would not only leave me without the use of my laptop or iPhone, but also that sensitive professional data would also be compromised or lost, raising liability issues.
My advice is for you to check out your policies for yourself. Considering how important our mobile phones and computing devices have become, the last thing you want is to face an expensive repair or replacement due to something that happened on the job. (In case you’re wondering, there are insurance companies that cover mobile devices against theft or virtually any kind of accident. The ones I found were The Worth Group, Apple Care, Square trade, mobile protect for iPhone. Some of these do not cover theft some do. The one I felt that was the most cost effective and covered thief was The Worth Group. As always do your own research and look at all your options. For now, I have only covered the items that the kids play with and the electronics at risk of being stolen.
Also, one important item to remember. Make sure you have any electronic device that might have access to patient data or has patient data under PIN. You dont want any HIPAA fines..
Yes, dorks, I’m back, and with a “Now, More Nerdy Than Ever!” post.
So I’ve realized recently that a lot of people don’t know about all the ways you can learn a ton of emergency medicine online, for free. I really enjoy learning this way, partially because there’s so many different ways to learn online that it keeps it from getting too boring, and keeps you keeping on. We’ll start with the quickest bites of knowledge, via email.
The University of Maryland Emergency Medicine Residency puts out little pearls every day, but did you know you can get them sent to you via email? Sign-up here, and you’ll get a little bit of knowledge every day in your inbox. (I can’t count the number of times I read one of these and within a week I’m searching my inbox to remember what exactly it said. Always pertinent and always good.)
Next up: the blogs. I’ve previously listed my favorites, but I’m going to highlight the most high-yield educational ones that I love:
- Top of that list would be Life in the Fast Lane, which literally posts so much content I can’t keep up. Take the Antidote Challenge, for example, which lists a ton of poisons and you have to go through and remember all the antidotes. High-yield, fast, great learning. I don’t know how they post so much.
- I really like the Emergency Medicine Forum. The poster summarizes a recent case she had, what the pitfalls and critical actions of the case were in her opinion, how she managed the case, with some references at the end.
- My Emergency Medicine Blog is kind of like the UMEM Pearls. The author takes something he learned from his shift and posts it to the blog with a reference. “Name the 4 indications for non-medical management of a Stanford B dissection,” for example.
- I can’t leave out my friend Michelle Lin’s Paucis Verbis cards. An index card summarizing what she thinks she needs to know about any number of problems in Emergency Medicine. You can’t get more high-yield.
How do I read all my blogs, by the way? I use Google Reader. It allows you to subscribe to RSS feeds of blogs (and journals and newspapers, and anything else that offers an RSS feed) so you can read all the content in one place. (An RSS feed is a way that sites can share their content with you without you having to visit their website.)
Next up: Podcasts/Videos.
- EMRAP is probably the most well-known (and is free for EMRA members!). But did you know there’s also a totally free video podcast version at EMRAP.tv? The Mel Herbert Empire also includes some free lectures from the All LA Conference and others.
- The EMCrit Podcast is both awesome and free, and I’ve learned a ton from it. (And Scott Weingart also posts here. So it must be good, right?) And a secret tip: if you search Google for pages on emcrit (type “site:emcrit.org” and then your search criteria, you’re bound to find something useful. For example, I found the “PAILS” mnemonic for reciprocal changes on this page.
- I’ve also just recently started listening to Keeping Up in Emergency Medicine, by the Vanderbilt EM gurus. It’s a quick, 30-minute podcast summarizing EM-relevant journal articles where Clay Smith and Jim Fiechtl give criticism and a summary of the findings.
- Secret tip: You can watch live USC Grand Rounds on Thursday mornings (California time) as well.
- Hennepin County EM has a bunch of great ultrasound and procedure videos on their YouTube channel.
- Run out of Hemocult developer? Need to irrigate someone’s eyes and don’t have a Morgan lens? Procedurettes by my absolutely fantastic attending Whit Fisher will save your butt every time.
Finally, Journal Articles. This only kinda-counts, but here’s a bunch of great online resources:
- EBMedicine. Insanely great, evidence-based diagnostic and management summaries on almost every EM topic by now.
- I heart The Emergency Medicine Clinics of North America. Shorter than EBMedicine but provide a great overview of many topics, and each issue focuses on a certain theme. You can access them as well if you’re a member of mdconsult.
- ACEP also provides its Critical Decisions in Emergency Medicine series, which are probably the shortest of all these options, but pretty good as well.
So, you’re asking yourself, how do I keep track of all of this? A private blog, of course. Whenever I read a good article or find something useful that I don’t want to forget, I summarize everything on the private blog and link or upload the PDF of the article I read it in. This way, I can always have access to the information as long as I have an internet connection. If I tried to store it all away in a notebook, it’d either get lost, fall apart, or I’d just forget it at home and be none the wiser.
As an emergency medicine resident, I remember taking tests and wondering where I stood compared to my peers. I would review different materials and focus on areas that I did not feel strong in. As a resident, I took the Ohio Acep review course and took their 700 question CD and reviewed all the explanations. I later was able to review the quiz questions and make suggestions.
Interesting enough, I was able to create the iPhone, Ipod Touch, * iPad edition of the quiz question for Ohio Acep. The app was just released and should show up on the app store in the next 48hrs. The app allows users to take the test and review each answer. It allows the user to focus on the questions or course materials they need to work on by creating custom test. The app also allows users to “know their ranking”, the app will ask users for an alias and will upload their test scores on each section of the test and will give an overall rank based on the users that have already taken the test. The ranking will update every time someone takes the test and clicks on ranking. To see the current ranking of beta testers and updated ranking please click here. To download the app or to see screen shots of the app click here.
* on iPad you will be able to double the size of the screen but the images might be slightly distorted.
Below I have included more information about the app.
Emergency Medicine Quiz Questions
On Sale for limited time, Price is 20% off.
Includes a new, 50-question pictorial review! Contains 700 review questions and referenced answers in an easy-to-use multiple choice format.
** “New Rankings feature, only users to see where they are ranked compared to their peers around the world. The app will rank each person based on subject and overall ranking depending on percent correct! Visit our website for more information.” **
The Emergency Medicine Review Course held annually by Ohio ACEP offers a comprehensive review for the physician preparing for the Qualifying examination, ConCert examination or continuous certification, or who simply desires an intensive review of emergency medicine. Attended by hundreds of physicians each year from across the country, this premier review course promotes high pass rates and receives high compliments.
Email us your feedback so we can make this app even better.
They have created this CD based on years of experience with preparing Emergency Medicine Physicians. The CD edition of this program retails for 100$ US Dollars.
The iPhone app is easy to use.
Endocrine, Metabolic & Nutritional Disorders
LifeLong Learning Self Assessment (LLSA)
This post is probably geared mostly toward residents and academics who have access to a university library for their researchin’ and journal readin’ (and especially nerdy residents and academics). I’ve made a little tool to hopefully help a few people find accessing journal articles from home a little easier. It’s called a bookmarklet.
What does it do? Well, if your university or hospital library has a proxy server (now we’re getting reallly nerdy), you can use it to try to auto-access journal articles on the web, without the hassle of going to your library’s website, logging in, finding the journal you want, then the article you want, then opening the PDF. It’s probably easier explained in the accompanying video, below.
[vimeo width=”620″ height=”465″]http://vimeo.com/9811158[/vimeo]
As Emergency Physicians we have to think outside the box and get as many clues as possible when confronted with a sick patient that can not speak for himself. Please do not forget to check their mobile device. Yes, sometimes it is in pieces or the battery is out but it might have helpful clues. This is no new concept. Currently, the iPhone has many apps in the app store. I wanted to highlight one particular app that was created by a paramedic. The name of the app is called SmartIce. The company is coming out with a lite edition in the near future for those of you that would like to test it out before purchasing it.
For more information, click here