Welcome In this Issue: - St. Mary's Medical Center

Volume 1, Issue 2WelcomeThe St. Mary’s Medical Staff News is distributed on a quarterly basis.You can browse through the newsletter page by page, or if you see an article that is of particularinterest to you, simply click on the title in the “In this Issue” section below to link directly to thearticle you would like to see.In this Issue:From the Chief Medical OfficerP & T Committee UpdatesH&P requirements prior to surgery orprocedureClinical Documentation ImprovementProgram update2011 OIG Work plan's Focus onPhysician ServicesLactation Services for Patients

From the Chief Medical OfficerThe Cornett Ball was just a few days away, and I needed a haircut. It was about 5:00 p.m., and I hadjust driven into Loogootee from a conference in Louisville. I thought I might find some place to get itdone. Even though we now live in Loogootee, I still had been getting my haircut in Evansville. Loogooteehas no JC Penny, Great Clips, Fantastic Sam’s or N’ Style Salon, so I called my brother,whom I knew got his haircuts in Loogootee. He gave me Elaine Wade’s number, and I gave her a callto see if she could get me in. After hearing the customary, “Hello” I began, “This is John Gallagher,and you don’t know me but you know my brother…”She interrupted me and said, “I know you John. Can you come right now? You’ll know me too whenyou see me.”“Sure,” I said, “How do I get to your place”?Even before I hung up I was wondering who this person was and how she knew me. I know mosteverybody in Montgomery where I grew up, and Loogootee is the next town east. So I know plenty ofpeople in Loogootee too, but I wasn’t placing this name. I know lots of Wade’s from around homebut no Elaine came to mind. Of course this was probably a married name I thought (Sherlock Holmeshas nothing on me). I called my brother back to see if he could enlighten me. “She is a Walton,” he Dr. John Gallagher, CMOsaid, “Mark and Joy’s sister.” This point of reference was all I needed. I know the Walton’s. It’s a bigfamily; a good family with plenty of ties and experiences with my own. The name means something and names usually do. When I was ateenager Dad would say, “Don’t do anything to damage our name.” A wise instruction that his dad gave to him.As physicians, we are well aware of the significance of a name. We value our own reputations and desire to be respected. In my experience,we are very sensitive to any encroachments on our reputation by others, but some of us underestimate the damage we do to ourselvesat times. Each interaction with a patient, nurse or colleague is added to the composite of the perception of who we are. We are defined byour actions, all of our actions, clinical and relational. We know ourselves; we know our heart and our intentions, but others see only ourdeeds.Fortunately, we our blessed with a great medical staff, and the vast majority have as much social and emotional intelligence and skill asclinical aptitude. I have made it a policy to inform members of our medical staff about any complaints that come my way, whether valid ornot. My hope is that awareness might lead to change where change is needed. Besides my desire to inform from a collegial standpoint or inaccordance with my role in medical staff policies that address such matters, there is an expectation as an accredited institution that themedical staff will perform ongoing professional practice evaluations (OPPE) of our members on a regular basis. This is nothing new, butwe want to get better at it and better at communicating it to our physicians.In the future you will receive better information that will address six general competencies. These competencies were developed by theAccreditation Council for Graduate Medical Education to evaluate the effectiveness of residency training and the American Board ofMedical Specialties for Maintenance of Certification. The Joint Commission adopted them in 2006. The six general competencies, or corecompetencies as they are sometimes called, are (1) patient care, (2) medical knowledge, (3) interpersonal and communication skills, (4)professionalism, (5) systems based practice and (6) practice based learning and improvement. As you can see, ongoing physician evaluationsinclude much more than clinical knowledge and skill.I found Elaine’s place. It was her home with an area dedicated to her business. One look at her and I knew I would have known she was aWalton if we crossed paths in on a different continent. As she combed and cut she asked me about Dad and my family, one by one andname by name. She talked about her involvement with Cursillo. I said, “Mom would have liked that.” She agreed, “Yes she would have.”This wasn’t just a polite affirmation. She knew she would have.Small talk while getting a haircut isn’t an earth shattering event, but then again this wasn’t just trivial conversation. It was an encounter oftwo families, one of many over the years - nothing special about it but another experience that adds to the composite of what is to be aGallagher or a Walton.Elaine brushed away the hair and said, “That’ll be ten dollars, John.”I paid the bill and as I left I knew it wasn’t the best ten dollar haircut I ever had; it was the best haircut.

P &T Committee UpdatesAuto-substitution of vitamin D analoguesThe P&T Committee has decided to continue with our long-standing formulary agent paricalcitol injection solution(Zemplar®) for the prevention and treatment of vitamin D insufficiency and vitamin D deficiency in chronic kidney diseasepatients. For doxercalciferol injection solution (Hectorol®) orders pharmacy will auto-substitute doxercalciferol to paricalcitol.The conversion ratio is 1 mcg paricalcitol IV = 0.6 mcg doxercalciferol IV. Any concerns may be addressed at P&Tor with your Medical Staff Department Chairman.Arixtra ® ( fondaparinux) Use is RESTRICTEDArixtra ® is on formulary for patients who develop thrombocytopenia or experience an adverse event to enoxaparin).Enoxaparin is our formulary product and is available generically. For prophylaxis, Arixtra® is more costly for our inpatientsand Day Treatment patients. The SMMC Pharmacy department contacted five retail pharmacies and found that the patientcharge at all five locations was significantly higher for Arixtra® versus generic enoxaparin. For obese patients who require aonce daily dose of >120mg or a twice daily regimen with generic enoxaparin, Arixtra® could be less expensive for inpatients.But for the MAJORITY of patients, generic enoxaparin is more cost effective. It is important to remember thatArixtra® is CONTRAINDICATED in patients with a creatinine clearance < 30ml/min. Please feel free to contact pharmacyon individual patients if you have questions. Pharmacists will contact physicians who order Arixtra® when the patient’s labsdo not indicate thrombocytopenia or an ADE to Lovenox® has not been documented.Gonadotropin-Releasing Hormone Analogues Formulary ConversionAt the October 2010 Pharmacy & Therapeutics Committee meeting, a therapeutic interchange from Lupron® (leuprolideacetate) IM to Eligard® (leuprolide acetate) SQ was reviewed and approved. The interchange will exclude pediatric patientsand "dispense as written" orders. If a patient is responding to Lupron® and the physician prefers that the patient remain onLupron®, please write the order as "dispense as written." The conversion is provided below and will begin on November 1,2010. Please contact the pharmacy department at extension 4815 if you have further questions or need additionalinformation.Non FormularyDrug OrderedLeuprolide (Lupron®) 7.5mgIMLeuprolide (Lupron®) 22.5mg IMLeuprolide (Lupron®) 30mgIMFormularyDrug DispensedLeuprolide (Lupron®) 3.75mg IM(Eligard® not available in this strength)Leuprolide (Eligard®) 7.5mgsubqLeuprolide (Eligard®) 22.5mgsubqLeuprolide (Eligard®) 30mgsubqAutomatic substitution to Zymaxid® approved by P&T CommitteeAfter review of input from the ophthalmologists, the P&T Committee has approved the following automatic substitution forthese ophthalmic quinolones. The conversion has been evaluated to ensure safety and efficacy. Please contact the pharmacyat extension 4815 if you have any questions.Therapeutic InterchangeOrdered Medication:Besifloxacin 0.6%(Besivance®)ophthalmic suspensionGatifloxacin 0.3%(Zymar®) ophthalmic solutionDispensed Medication:Gatifloxacin 0.5%(Zymaxid®)ophthalmic solutionDirections: according to package insertGatifloxacin 0.5%(Zymaxid®) ophthalmic solutionDirections: according to package insert

H&P requirements prior to surgery or procedureDr. John Gallagher, SVP, CMOThe Medicare Conditions of Participation mirror The Joint Commission Requirements for the process of completing anddocumenting patient History and Physicals. These requirements are straightforward, leaving no margin to amend. To ensurethe safest scenario and outcome for the patient, both CMS and TJC require the physician complete a recent assessment of thepatient after the patient has been admitted or registered, understanding that a patient’s status could change immediately priorto admission or registration, thus potentially jeopardizing the safety of the surgery or procedure.The Medical Staff Policy states:A medical history and physical examination must be completed no more than thirty (30) days before or twenty-four (24)hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.When the medical history and physical examination is completed within 30 days prior to admission, an updated examinationof he patient, including any changes in the patient’s condition must be completed and documented within 24 hours after admissionor registration, but prior to surgery or a procedure requiring anesthesia services.Most physicians are adhering to the requirements, but there are some that are not,Based on the above requirements, the following scenarios would not be acceptable:1. Patient has not had a recent (within 30 days) History and Physical. The Physician sees the patient in his/her office andwrites note: see previous H&P.Correct action: A new H&P is completed within 30 days of admission/registration, and an update note is completed afteradmission/registration if new H&P was not completed within 24 hours of admission/registration.2. Patient has not had a recent (within 30 days) History and Physical. After the patient is admitted/registered, the Physicianwrites a progress note stating see previous H&P, no changes.Correct action: A new H&P is completed.3. Physician or office staff date a previously performed H&P with the date the Physician sees the patient in the office priorto surgery. NOT ACCEPTABLECorrect action: The only date that can be accepted for the H&P is the date of service – i.e. the date the H&P was performedwith the patient.Thank you for your review of and attention to these requirements. Please contact me with any questions.Clinical Documentation Improvement Program updateJA Thomas and Associates (JATA) has assisted St. Mary’s Medical Center in the implementation of Compliant DocumentationManagement Program (CDMP) since October 2008. For those still unfamiliar with the program, CDMP is a clinicalapproach to improving documentation within compliance standards and managing DRG assignments on a concurrent basis.The benefits of the program are numerous and include improved documentation, increased specificity of patient diagnosis,capture of patient’s true severity of illness and resource consumption, adjusted expected mortality rates, more accurate reflectionof the hospital’s CMI, more accurate reflection of physician profiles, providing a foundation for CMS complianceand supporting Joint Commission documentation standards.Medicare and Anthem Blue Cross medical records on adult inpatient units are reviewed and clarification questions areposed to the attending and consulting physicians as warranted. The clarification process is direct, brief, to the point, andclinically based. The decision process to agree or disagree rests with the physician. A 100% response rate is desired andexpected regardless of the answer. A documentation best practice is to consistently document the problem list diagnosesdaily and indicate when problems are resolved. When a consultant is requested for specific issues, the attending should reiteratethe consultant’s diagnoses list in the discharge summary so that the record is accurate and complete.Continued on Page 5

Continued from Page 4If you have any questions regarding this process, contact one of the five clinical documentation specialists: Karen Arendell,RN, Paula Kaetzel, RN, Diane Barth, RN, Linda Bailey, RN or Tammy Reidford, RN. They can be reached viapager on the x7900 line voice activated pager directory.2011 OIG Work plan's Focus on Physician ServicesThe OIG recently released their 2011 Work plan which targeted several physician services for review. The following are just two of theidentified services at risk.Place of Service (POS) Errors: A review of physician coding of POS on Medicare Part B claims for services performed in ambulatorysurgical centers (ASC’s) and hospital outpatient departments. Medicare pays a higher amount when a service is performed in a nonfacilitysetting, such as a physician office, than it does when the service is performed in a hospital outpatient department or, with certainexceptions, in an ASC.Coding and Payments of Evaluation and Management Services: The OIG will review E&M claims to determine whether coding patternsvary by provider characteristics. The inspectors will also study E&M utilization to identify trends in the level of service, to seewhether certain types of providers tend to bill lower or higher-level codes. Additionally, they plan to examine the documentation forE&M services due to an increased number of instances where identical or very similar documentation was used for different E&M codes.The OIG believes that many physicians rely on EHR systems automated documentation features which may cause improper paymentsbased on identical documentation.According to a recent article in Part B News, the OIG will single out “error-prone providers with high claims denial rates over the pastfour years.” It states the OIG will use the last four years of data from CERT (CMS’s Comprehensive Error Rate Testing) program toidentify these providers. However, the OIG may also use CERT data to identify providers likely to be error-prone and review them aswell. To determine if you are potentially at risk for review check with your Office Manager &/or billing service for your volume ofCERT request.If you have questions regarding the OIG Work plan focus on physician services or other compliance questions please contact CorporateCompliance Services at 485-6500.Lactation Services for Patients - A Testimonial by Dr. Stephen Lanzarotti“My wife has great things to say about the lactation specialists here at St. Mary's. Stephanie was very helpful to us during thisvery difficult time. Elise is our first baby, and, as physicians, we understand the benefits of breast milk for infants. However,what we were not aware of, is how difficult it may be for babies to initiate this ‘natural’ process of latching on. Stephaniemade herself available over the phone and for outpatient visits, and her professional demeanor and patience with two nervousparents made all the difference. After about two weeks, Elise and mom both settled in to the whole process, and everythingwent very well from there. If it wasn't for the lactation specialists here at St. Mary's, then our baby likely would not havebeen able to have breast milk for the first year of her life. Elise and my wife and I would like to thank all the lactation specialists,especially Stephanie Kruse, for all the wonderful work they do and let them know that they did make a difference forour baby.”St. Mary’s staff of six Lactation Specialists are here to serve your patients! They offer:Inpatient & Outpatient ConsultationsConsultations for breastfeeding infants in the NICUWeight Checks24-Hour Phone Support at 812.485.4322Monthly Support GroupMonthly Breastfeeding ClassesResources for supplies and pump rentals through St. Mary’s Medical Equipment