Faculty Bibliography

Background: Emergency medicine professional reimbursement-in particular, the Evaluation and Management levels-is based on Medicare's rules defining the complexity of care. Services are only reimbursable if they are properly recorded. Therefore detailed documentation is essential for optimal compensation. Critical care follows a different set of rules than other Evaluation and Management levels and a lack of clinician awareness of these rules leads to incomplete documentation and under billing. Objectives: The goal of this study is to: 1. Identify gaps in critical care documentation knowledge among emergency physicians. 2. Determine if these gaps can be filled via a selfadministered online training module. 3. Determine whether improvement in knowledge can improve documentation and enhance reimbursement. Methods: Critical care charts were examined in an urban tertiary care center with approximately 68,000 ED visits per year. Pre-intervention, 1.2% of charts were coded as "critical care"; less than the national average of 2.5%. Physicians completed a pre-module assessment, followed by a 15-minute online educational module, followed by a post-module assessment. Critical care rates were measured during the months preceding and following module completion. Results: 1. Gaps in knowledge were defined when average correct pre-assessment response was < 75%, revealing deficiencies in specific aspects of critical care documentation, which may be reflected in the critical care rate. 2. Post-module assessments had an overall higher correct response rate (65.9% to 84.8%, p<0.001). Specifically for knowledge gap questions, the correct response rate increased from 53% to 86.5% (p<0.001). 3. After all clinicians completed the teaching module, ED critical care rates increased from 1.4% (Nov-Dec, 2015) to 3.22% (Mar-Apr, 2016), an increase of 129% that trended towards statistical significance (p=0.058). This extrapolates to an annual increase in reimbursement of $103,900, based on the ED's specific average collection rates. Conclusions: The training module was able to identify and correct gaps in critical care knowledge, likely leading to an increase in proper charting and coding and a subsequent increase in revenue. Additionally, the effectiveness of a short, easily distributed teaching module carries broad implications for future physician education initiatives

Importance: In an effort to regulate physician conflicts of interest, some US academic medical centers (AMCs) enacted policies restricting pharmaceutical representative sales visits to physicians (known as detailing) between 2006 and 2012. Little is known about the effect of these policies on physician prescribing. Objective: To analyze the association between detailing policies enacted at AMCs and physician prescribing of actively detailed and not detailed drugs. Design, Setting, and Participants: The study used a difference-in-differences multivariable regression analysis to compare changes in prescribing by physicians before and after implementation of detailing policies at AMCs in 5 states (California, Illinois, Massachusetts, Pennsylvania, and New York) that made up the intervention group with changes in prescribing by a matched control group of similar physicians not subject to a detailing policy. Exposures: Academic medical center implementation of policies regulating pharmaceutical salesperson visits to attending physicians. Main Outcomes and Measures: The monthly within-drug class market share of prescriptions written by an individual physician for detailed and nondetailed drugs in 8 drug classes (lipid-lowering drugs, gastroesophageal reflux disease drugs, diabetes drugs, antihypertensive drugs, hypnotic drugs approved for the treatment of insomnia [sleep aids], attention-deficit/hyperactivity disorder drugs, antidepressant drugs, and antipsychotic drugs) comparing the 10- to 36-month period before implementation of the detailing policies with the 12- to 36-month period after implementation, depending on data availability. Results: The analysis included 16121483 prescriptions written between January 2006 and June 2012 by 2126 attending physicians at the 19 intervention group AMCs and by 24593 matched control group physicians. The sample mean market share at the physician-drug-month level for detailed and nondetailed drugs prior to enactment of policies was 19.3% and 14.2%, respectively. Exposure to an AMC detailing policy was associated with a decrease in the market share of detailed drugs of 1.67 percentage points (95% CI, -2.18 to -1.18 percentage points; P < .001) and an increase in the market share of nondetailed drugs of 0.84 percentage points (95% CI, 0.54 to 1.14 percentage points; P < .001). Associations were statistically significant for 6 of 8 study drug classes for detailed drugs (lipid-lowering drugs, gastroesophageal reflux disease drugs, antihypertensive drugs, sleep aids, attention-deficit/hyperactivity disorder drugs, and antidepressant drugs) and for 9 of the 19 AMCs that implemented policies. Eleven of the 19 AMCs regulated salesperson gifts to physicians, restricted salesperson access to facilities, and incorporated explicit enforcement mechanisms. For 8 of these 11 AMCs, there was a significant change in prescribing. In contrast, there was a significant change at only 1 of 8 AMCs that did not enact policies in all 3 areas. Conclusions and Relevance: Implementation of policies at AMCs that restricted pharmaceutical detailing between 2006 and 2012 was associated with modest but significant reductions in prescribing of detailed drugs across 6 of 8 major drug classes; however, changes were not seen in all of the AMCs that enacted policies.

Background: The work of ED physicians is complex, with increasing patient volumes, rapidly changing EHRs, and growing documentation regulations. Medical scribes aim to address these problems, workflow efficiency, job satisfaction, and increase reimbursements. Despite the advantages, facilities remain resistant to adopting a scribe program for several reasons, including cost, addition of ED personnel, and incorporation new roles within an established workflow. Looking to minimize challenges, we propose modified telescribes utilizing a pre-established, qualified volunteer program. Workflow consists of providers connecting to telescribes via audio/video from secure mobile devices. Proper consent is obtained and telescribes document patient interactions in real time. Providers reap benefits of note drafting and volunteers gain valuable education only obtainable through collaboration with ED providers. Objectives: Assess physician, hospital volunteer, and patient receptiveness to scribes and telescribes. Methods: A survey was sent to 88 attendings (RR=29%) and 59 residents (RR=39%) employing yes/ no, multiple choice, and Likert scale questions to assess receptivity to scribes and telescribes; no supplemental information. A second survey evaluated hospital volunteers' desire to participate (n=50; RR=44%). A third survey (n=12) gauged patient responses to both scribes and telescribes services using a likert scale after a brief explanation of the services. Results: Of providers surveyed, 84% never used a traditional scribe or telescribe, while 85% indicated a desire to work with them. Furthermore, 95% agreed that learning to use a scribe would benefit them in the future and 75% agreed to adjust workflow to accommodate a scribe. Despite willingness to use a traditional scribe, 45% indicated they would not use the telescribe service (free-text rationales related to inconvenience). Secondly, 95% hospital volunteer respondents were interested in the scribe position. Finally, a patient survey showed zero were uncomfortable with presence of a scribe and 16% and 25% were uncomfortable with an audio or video scribe, respectively. Conclusion: Our results indicate patients and providers are more comfortable with a traditional scribe model and implementation of a telescribe model requires addressing workflow and privacy concerns of provider and patient

Background: The complexity of healthcare demands physicians develop their skills as both clinicians and leaders, but traditional medical education has not embraced a comprehensive leadership curriculum. To meet this need, the NYU School of Medicine developed a "Physician as Leaders" workshop for its students. Education Objectives: The workshop's goal is to provide students with the attitude & behavioral skills necessary to function as members and leaders of highly effective teams. Its objectives are 1. Begin to develop leadership skills, specifically in effective communication and conflict management, 2. Recognize the impact effective communication has on patient care, and 3. Reflect on personal strengths and begin to produce a personal development plan. Curriculum: The 90-min workshop was presented to 172 third year students in groups of 18. Four physicians (this included 3 medical directors and 3 other leaders within the medical school) led the course. Role play scenarios featured physicians in confrontational roles and a medical student mediating the conflict. Students also role played scenarios in small groups. A communication and conflict management didactic was given after the simulations. Results: A post-workshop survey with a 64% response rate revealed that 71% of students felt the workshop met objective 1, 67% objective 2, and 66% objective 3 (see table). Conclusion: Medical schools under prepare students for leadership positions. Conflict management and communication skills are essential to prepare medical students for daily professional interactions. This workshop was well received, and lays the groundwork for an approved 20-hr, 4-year longitudinal curriculum to teach core principles of leadership including time management, teamwork, operational improvement, and others. (Table Presented)

Introduction: The need for physician leaders continues to grow. In response, medical schools have expanded the availability of administration related dual degree programs including Master of Business Administration (MBA) and Master of Public Administration (MPA). Students enrolled in these programs often receive very specialized training about policy, business, and management but many programs do not offer a mechanism to integrate this new knowledge with their existing medical training. Educational Objectives: We developed the Seminar in Healthcare Management for medical students who were pursuing a secondary MBA or MPA degree. The goal of this curriculum was to provide early exposure to physician leaders from a variety of career paths who have integrated administrative, leadership, or policy work with their clinical careers to enable our students to explore future opportunities. Curricular Design: The Seminar in Healthcare Management was a six month long program with ten participants, eight MD/MBA candidates and two MD/MPA candidates. The curriculum consisted of monthly seminars supported with outside reading assignments and mentorship opportunities. Speakers were industry experts, professors, and clinical administrators from diverse backgrounds. Seminar topics included: Healthcare Delivery Systems, Medical Malpractice and High Risk Medicine, Physician Payment Policy, Physician Leadership, Health Care and Global Supply Chain, and Hospital Organization Community Commitment. Impact/Effectiveness: The effectiveness of the seminar was assessed using post session surveys. On a scale of 1-5 (1-poor, 5-outstanding), the mean scores were: reading materials (4.61), lecture content (4.45), presentation style (4.57), overall (4.51). With the success of the first year of the program, we have been advocating to incorporate the Seminar in Healthcare Management as a required part of the core MD/MBA and MD/MPA curricula and to expand the program to other dual degree students

Background: The prevalence of completed Advance Directives (ADs) by adults range between 18-36%. With 75% of Americans 65 or older being seen in the ED in the last six months of life, knowledge of patient goals for care and ADs are essential to provide medical management specific for each patient. Objectives: The purpose of this study is to: 1) assess the knowledge of ADs in patients presenting to the ED; 2) explore correlation between the presence of ADs and demographic data; and 3) assess whether patients are willing to speak to ED staff about their end of life care. Methods: An IRB-exempt, voluntary, paper-based survey was distributed to a convenience sample of patients over the age of 25 presenting to the EDs of an academic urban public hospital and private hospital between June 25, 2013 and July 28, 2013. Results: During the study period, 329 participants completed the survey, 189 from the public hospital and 140 from the private hospital. The majority of participants 88.1% (290/329) failed to identify the components of an AD. Of our patients, 54.7% (180/329) have never had a conversation with anyone about ADs, and 89.1% (283/329) have not spoken to their primary care doctors about ADs. Of patients over the age of 65, 31.6% (18/57), have never had a conversation about ADs. At the same time 75.4% (248/329) of patients feel comfortable speaking with an ED physician about ADs, and 62.9% (207/329) of patients think that the ED should ask their patients about end of life care. Patients in the public hospital were less likely to have ADs, with only 12.7% (24/ 189) having spoken to primary care doctors about ADs, compared to patients in the private hospital, where 45% (63/140) have spoken to their primary care doctors about ADs. Conclusion: Many patients are unaware of the components of an AD. A majority of patients presenting to the ED feel comfortable about discussing ADs with an ED physician. The ED visit offers an opportunity to educate patients about ADs