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Hospital Medicine

Featured Recruiter: Victoria Wrede

Posted on Mon, Mar 07, 2016
Featured Recruiter: Victoria Wrede

Looking to make a career change? Meet recruiter Victoria Wrede!

Name: Victoria Wrede
Position: Recruiter – Hospitalist & Anesthesia
Division: South
Location: St. Petersburg, Fla.

Education: Associate Degree, Certified Hospitality Supervisor

Years with EmCare: 6 years

Years in the recruiting field? 4 years

Why did you decide to become a recruiter? Before changing career paths into healthcare, I spent more than 20 years working in the hospitality industry. Healthcare and hospitality are similar, since they both function 24 hours a day and require a high level of customer service. I started with EmCare in 2010 in the scheduling department and transferred into recruiting after almost two years. The intent was to learn more about the hiring process and to see if I could help make a difference with staffing.

How does your experience enable you to connect candidates with the right positions? As a result of years in customer service, I'm able to connect with candidates and identify the best demographic area and program structure to fit their lifestyle or goals.

Describe one of your greatest professional accomplishments. My first year recruiting with EmCare I had a Chief Resident who only wanted to work at one specific location in a highly desired demographic area. She was initially declined for unsubstantiated reasons. I was an advocate for her and was able to get her the job. To this day she is still at the same facility and has been an asset not only to that program but has worked at other facilities when we were short staffed.

What makes EmCare attractive to candidates? EmCare has been focusing on growth in other service lines, including Hospital Medicine, Anesthesia, Radiology, and beyond. The longevity and reputation of the company attracts well-qualified providers.

Describe your ideal candidate. A candidate who knows what demographic area and program structure they are focused on is ideal. “Job clickers” or indecisive candidates who don’t know where they want to go can be frustrating and time consuming.

How important is the “relationship” between recruiter and candidate? The recruiter builds trust with the candidate and that is the foundation for a solid relationship.

What do you like most about working at EmCare? The best part about working at EmCare is the staff. I have met some very dynamic people who have influenced me tremendously both personally and professionally.

What do you enjoy outside of work? I enjoy spontaneous trips to major sporting events and theme parks with my family. I recently went to the Orange Bowl in Miami and then to Phoenix for the Fiesta Bowl in one weekend excursion.

What’s your favorite inspirational quote? “Real integrity is doing the right thing, knowing that nobody’s going to know whether you did it or not” Oprah Winfrey

What qualities make a successful recruiter? A successful recruiter follows through and has the best interest of the candidate and practice in mind.

Why should physicians and advanced practice providers join EmCare? EmCare is a physician-led company, which means our decision makers have paid their clinical dues and manage from experience.

What should residents do now to prepare themselves for future hiring opportunities? Identify your short-term and long-term goals post residency. Stability and a clean record will help candidates get their ideal positions.

What “insider tips” do you have for anyone applying to EmCare? Turn your paperwork in a timely manner. Communicate with your recruiter regarding your intentions. The ideal position might not be available today but the more we know, the sooner we can contact you when the opportunity arises.

How should a candidate follow up after an interview with you? Within a few days of the interview it's essential that you provide feedback on the experience so we can relay the information to administration and our leaders. This will allow us to advocate for you if it's a position you are interested in.

Where do you look for candidates, both in-person and online? Do you use social media? Yes social media is a great tool. I make a lot of connections at conferences, job fairs and residency dinners.

Tell me about your ideal candidate. What kind of clinical and educational experience is in demand now? The Hospitalist field is growing rapidly and certain skill sets are in high demand, such as the ability to perform procedures, run codes and exhibit leadership. An ideal candidate will tell me about their strengths so I can help market them to leadership. Flexibility and willingness to be a team player is also an asset.

Why should a provider want to work for EmCare? What’s different or unique about the culture, the opportunities, or the work itself? Our company is always looking ahead to next big healthcare trend which will provide optimal patient care. We offer many opportunities to help achieve your personal and professional goals.

How would your co-workers describe you? Hard working, diligent and non-conventional.

Tell us something that most people at work don't know about you. I am very sarcastic but that is an inherited trait.

What was the last book you read? I only read newspapers and magazines, short and to the point.

What personal accomplishment are you most proud of? My greatest accomplishment by far has been raising my two children: Austen, 17, and Alexis, 16, and by giving them the stability, opportunities and experiences I wasn’t afforded as a child. The cycle can be broken.


In Case You Missed It

Posted on Fri, Feb 26, 2016
In Case You Missed It

Our weekly roundup of healthcare headlines featuring articles about physician burnout, anesthesia for orthopedics, cutting the cost of healthcare, treating the homeless, sepsis, Choosing Wisely in hospital medicine and more!

The Doctor’s New Dilemma - New England Journal of Medicine

Pay for Medical School Through Service - The Association of American Medical Colleges

In My Shoes: Facing burnout as emergency medicine physician - Richmond Times Dispatch

ER Goddess: A Career in Medicine is a Cruel Mistress - Emergency Medicine News

Anesthetic Care for Orthopedic Patients: Is There a Potential for Differences in Care? - Anesthesiology

Crash Cart: Armed guards in the ED, high deductibles and Valentine’s Day - Emergency Physicians Monthly

A Novel Plan for Health Care: Cutting Costs, Not Raising Them - New York Times

The challenges this doctor faces when caring for the homeless - KevinMD

The Third International Consensus Definitions for Sepsis and Septic Shock - JAMA

An Army of One No More: Hospitalists Choosing Wisely with Nurses - Society of Hospital Medicine

CMS and major commercial health plans, in concert with physician groups and other stakeholders, announce alignment and simplification of quality measures - CMS

7 key findings on physician placement - Becker's Hospital Review

In case you missed it, check back next week!


10 Tips for Emergency Medicine-Hospital Medicine Collaboration

Posted on Wed, Jan 13, 2016
10 Tips for Emergency Medicine-Hospital Medicine Collaboration

By Ginger Wirth, RN

According to Merriam-Webster, the full definition of collaborate is:

  1. To work jointly with others or together, especially in an intellectual endeavor
  2. To cooperate with or willingly assist an enemy of one's country and especially an occupying force
  3. To cooperate with an agency or instrumentality with which one is not immediately connected

I know that collaboration in healthcare can sometimes seem like assisting another country. The relationships between departments, disciplines, practices and partners have both rewards and challenges. Collaboration is key on so many levels to achieving the best outcomes and delivering the overall best care for patients. This is essential between nursing and providers in the emergency department when planning and executing care. Effective communication and collaboration plays into the safety, clinical quality and satisfaction of each patient’s visit.

Another important collaborative relationship is the emergency physician and the hospitalist. Continuity of care and the handoff of the admitted patient are essential to those same aspects of the patient’s overall experience: safety, satisfaction and clinical quality. This collaboration should happen not only when directly dealing with a patient, but also when processes, order sets or clinical pathways are being developed and reviewed. Healthcare is unique in the fact that we have governing and regulatory bodies that have standards, guidelines and measures that set basic expectations for outcomes. However, ultimately it is the provider-to-provider relationship and collaboration where the “magic happens.” Strong relationships among emergency medicine and hospital medicine teams have proven not only to meet standards but exceed them. Best practice is to have regular team meetings between these specialties to discuss opportunities and share the wins and outcomes of cases. Again, strong collaboration is a “win-win” for all – especially for the patients to which we provide care.

10 Lessons in Collaboration

Regardless of your industry, collaboration is so important. Here are some tips from Deborah B. Gardner PhD, RN, CS:
  • Lesson #1: Know thyself. Many realities exist simultaneously. Each person's reality is based on self-developed perceptions. Requisite to trusting yourself and others is in knowing your own mental model (biases, values, and goals).

  • Lesson #2: Learn to value and manage diversity. Differences are essential assets for effective collaborative processes and outcomes.

  • Lesson #3: Develop constructive conflict resolution skills. In the collaborative paradigm, conflict is viewed as natural and as an opportunity to deepen understanding and agreement.

  • Lesson #4: Use your power to create win-win situations. The sharing of power and the recognition of one's own power base is part of effective collaboration.

  • Lesson #5: Master interpersonal and process skills. Clinical competence, cooperation and flexibility are the most frequently identified attributes important to effective collaborative practice.

  • Lesson #6: Recognize that collaboration is a journey. The skill and knowledge needed for effective collaboration takes time and practice. Conflict resolution, clinical excellence, appreciative inquiry and knowledge of group process are all life-long learning skills.

  • Lesson #7: Leverage all multidisciplinary forums. Being present both physically and mentally in team forums can provide an opportunity to assess how and when to offer collaborative communications for partnership building.

  • Lesson #8: Appreciate that collaboration can occur spontaneously. Collaboration is a mutually established condition that can happen spontaneously if the right factors are in place.

  • Lesson #9: Balance autonomy and unity in collaborative relationships. Learn from your collaborative successes and failures. Becoming part of an exclusive team can be as bad as working in isolation. Be willing to seek feedback and admit mistakes. Be reflective, willing to seek feedback, and admit mistakes for dynamic balance.

  • Lesson #10: Remember that collaboration is not required for all decisions. Collaboration is not a panacea, nor is it needed in all situations.

To read more about emergency medicine-hospital medicine integration and collaboration, read our recent white paper, “Integration Changes Everything.”

Ginger Wirth

Ginger Wirth, RN, joined EmCare in 2013 as a Divisional Director of Clinical Services for the Alliance Group. Her goal is to make positive changes in healthcare by helping others focus on quality, excellence, and the overall patient experience. Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20-plus year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients.


The Future of Hospital Medicine: The Tools and Integrations Shaping the Specialty

Posted on Tue, Dec 22, 2015
The Future of Hospital Medicine: The Tools and Integrations Shaping the Specialty

By Francisco Loya, MD
The technologies we are using to improve the delivery of care in hospital medicine are showing great promise – if not outright success. EmCare’s Hospital Medicine team is deploying innovations that improve operational efficiency, enhance quality of care, ease staffing challenges and upgrade billing and coding practices. As these tech tools become more prevalent, I would argue that the future of hospital medicine has arrived, and with it the promise of better care and lower costs.
Operational Efficiency in a VBP World

The value-based purchasing environment has increased pressure on hospital medicine teams. The onus is largely on us to try to prevent readmissions while still being expedient with inpatient care and discharge to help increase patient satisfaction. Through automation, we have been able to reduce wait times for patients, streamline the admissions process and improve rounding and charge capture.
Through technology, we have created a platform for emergency physicians and hospitalists to meet and confer virtually so that the hospitalist may admit patients without having to visit the emergency department. This platform has allowed for a decrease in boarding times by 2.5 hours, an 8 percent reduction in “left without treatment” rates and overall improvement (to nearly 100 percent) in CMS core measure compliance. A by-product of the reduced wait times for patients is an increase in E.D. volume of nearly 27 percent. This has meant more volume for the hospital without any additional strain on resources.
Another technology we use coordinates admissions between hospitals and primary care physicians. This direct admit system is enacted with a click of a button by the primary care physician, who can then complete an online form to admit the patient to the hospital. The platform also generates a “boarding pass” for the patient to bypass the E.D. and go straight to the inpatient floor. Not only does this technology improve cohesion between hospitals and primary care physicians, it also improves patient satisfaction since wait times are reduced. That, in turn, leads to a decrease in E.D. crowding and an increase to the hospital’s referral base.
These tools certainly don’t substitute for human interaction and can’t guarantee improved quality of care, but they do allow for greater control and management over various administrative protocols. The results from these tools have been positive – both for hospitals and patients. Doctors are able to increase their focus on patient care, and most hospital medicine support staff and caregivers say their jobs are easier and more efficient.
Telemedicine Can Ease Staffing Woes

Telemedicine is another futuristic technology that’s growing in use and importance. Hospitalists are benefitting from virtual care and robotic caregivers who can help hospitals meet staffing and practice challenges.
“Five years ago, the technology wasn’t there,” said Angel Iscovich, M.D., a divisional CEO of staffing and innovation for EmCare. “The safeguards for patient privacy to protect encounters conducted over video just weren’t ready.”
Now we have cybersecurity that allows doctors to engage with patients via a video screen and webcam. The practice is easing staffing shortages for hospitals and putting patients at ease since they’re able to meet with highly qualified specialists no matter where those physicians are.
And, patients are responding positively to robot doctors. Robots are slowly taking over rounding duties in some hospitals, acting as nocturnists that provide after-hours care. Companies that provide "robodocs," such as InTouch Health, report that its robots can monitor heart sounds and connect to EMRs to improve care and efficiency. The robots are controlled with a tablet, so a caregiver can operate the robots onsite, or doctors can control the robots remotely for virtual visits. The robots can easily round on the intensive care unit, interface with the equipment and provide more expedient and effective rounding than some of their human counterparts.
Cameras for the “robodocs” provide enough mobility and resolution to offer high-quality care. One doctor, through the use of video screens and robots, can cover multiple facilities while staying in one place. Hospitals can reduce costs by “sharing” the off-site physicians. And patient satisfaction scores have, so far, not suffered because of the technological intermediaries. If anything, early studies show that patients believe the robodocs and tele-visits provide access to quality providers that otherwise would be unattainable.
Bundled Payment Initiative Requires Integration

The Bundled Payments for Care Improvement (BCPI) initiative is a federal government program designed to help manage costs for Medicare patients. BCPI allows disparate organizations to combine services and arrange for payment models that include financial and performance accountability for episodes of care. The program includes four broadly defined models of care to include various combinations of pre-acute care, acute care and post-acute care.
With this recent inducement for organizations to work together, clinical integration is more important than ever. Companies will need to attain certain levels of synergy outside of their own organizations. There are, however, some companies that are diversified enough to maximize the potential benefits of BCPI for themselves, their clients and patients. This type of self-integration tends to be more reliable because they have more control over more pieces of the BCPI integration – they are better able to manage quality of care across the care continuum. Through integrated services – for example, a post-acute care company working with hospitalists – costs are reduced, which increases patient satisfaction, since that patient is less likely to need readmitting and can receive care at home (where the patient generally prefers to be). With the cost offset, reimbursement from CMS can be more meaningful for the hospital as well.
Medical Command Center Provides Remote Care Coordination

Technology is allowing post-acute care companies greater control over the care offered in a patient’s home as webcams and video screens put caregivers face-to-face with patients. Our parent company, Envision Healthcare, has pioneered the Medical Command Center, a new concept that allows healthcare providers to check in with patients to regulate prescriptions, check vitals and confirm operation of in-home medical devices. Medical Command Center staff use their high-tech control rooms to manage care for patients in a number of states and can quickly dispatch a caregiver, such as a mobile integrated paramedic or physician assistant, to a patient’s home when necessary.
These software advancements, tech tools and integrated services are becoming more pervasive as technology advances and providers find new ways to effectively integrate their services. By focusing on operational protocols like admissions, rounding and discharge, along with streamlined billing practices and more seamless care, patients reap the benefits of high-quality personal care provided by caregivers while waiting less, paying less and visiting hospitals and doctors’ offices less.
By embracing the technologies that are available now and those on the horizon, hospitalists create more efficient practices for themselves and their patients, and are better able to focus on patient care, as opposed to the administrative processes that often keep us from the bedside - where many physicians prefer to be.

Francisco Loya
Francisco Loya, MD, MS, is chief executive officer of EmCare Hospital Medicine. In addition to his EmCare duties, Dr. Loya serves on several committees for the Society of Hospital Medicine, including the Practice Administrators Committee, the Hospital Quality and Patient Safety Committee and the Information Technology Committee. As a physician, Dr. Loya specializes in internal medicine. He earned his undergraduate degree at Rice University, earning a B.S. in Biochemistry and Molecular Biology. His M.D. came from the University of Texas Southwestern Medical School in Dallas and his internal medicine residency was completed at Brigham and Women’s Hospital in Boston – an affiliate of Harvard Medical School. Dr. Loya has also earned his Master of Science degree in Healthcare Management from the Harvard School of Public Health. After earning his master’s degree, Dr. Loya created the technology he named CMORx, which is now offered exclusively by EmCare.


The Basics of Billing for Critical Care Services: What Physicians May Not Know

Posted on Thu, Dec 17, 2015
The Basics of Billing for Critical Care Services: What Physicians May Not Know

By Mark J. (Jeff) Slepin, MD, MBA, FACEP, and John Coyle, DO

Documentation of professional services that reflect the cognitive (Evaluation and Management – E&M) and procedural services that providers perform is an essential activity in the day-to-day practice of emergency and hospital medicine.

Perhaps you have seen a breakdown of the acuity levels of the services that you render. Do you ever wonder why certain conditions that seemingly require less work than others are assigned the identical E&M code? Does this accurately reflect a comparable amount of work, risk to the patient, generation of Relative Value Units (RVUs – a reflection of the work performed), and revenue for the practice?

Many providers are unaware of some of the nuances of documentation, coding and billing, all of which are essential to the provider getting proper credit for the services rendered and the practice generating the appropriate revenue for medically necessary services. And, do you understand exactly how the revenues are generated to provide the compensation for the work performed?

The Basics of Billing

Getting credit for the work performed and evaluation of the risks faced by the patient are essential for professional services. Most patient encounters by ED physicians and hospitalists result in the generation of a charge for an E&M service, based on the patient’s acuity, medical decision-making, and the elements of the history and physical examination. Critical care services are performed to a greater extent than most physicians realize. So, just what services qualify for classification as “critical care?”

Critical care is defined as a physician’s direct delivery of medical care for a critically ill or unstable patient. A critical illness is one with a high probability of sudden, clinically significant or life-threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently, including direct personal management by the physician, with life and organ supporting interventions that require frequent, personal assessments and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration of the patient’s condition.

The following table illustrates examples of conditions and interventions that may qualify for critical care.

Critical care services require the physician’s documentation of the cumulative time spent in critical care activities and must include a minimum of 30 minutes attending to the patient, which includes more than just continuous attention at the bedside. Instead, activities considered within “critical care time” include all of the following:

  • Time spent at the bedside evaluating and managing the patient
  • Time spent on activities that contribute to the patient’s care, such as reviewing old records, laboratory results, and imaging results
  • Time spent in consultations with other physicians
  • Time spent with family, whether to obtain a history or to discuss treatment options when a patient is not able to participate; and
  • Performing any of the following services:
    • Gastric intubation
    • Interpretation of blood gases
    • Interpretation of cardiac output
    • Interpretation of chest X-rays
    • Interpretation of pulse oximetry
    • Temporary transcutaneous pacing
    • Vascular access procedures
    • Ventilator management

The services listed above cannot be billed for separately when critical care services are provided, but the time spent performing these procedures counts toward the computation of critical care time.

Why It’s Important to Report Time Spent Providing Critical Care Services

The codes for most E&M services, while associated with a usual amount of time spent in their performance in the code descriptor, don’t require the physician to report the amount of time spent (with the exception of inpatient discharge day management services and services in which counseling and/or coordination of care constitute > 50% of the encounter time). Thus, the coder can analyze the problems (diagnoses, signs and symptoms), medical decision-making complexity, and the medically necessary elements of the history and physical examination to assign the appropriate code.

In contrast, critical care service codes can only be assigned if the physician INDICATES THE AMOUNT OF CUMULATIVE TIME SPENT IN THE PERFORMANCE OF CRITICAL CARE ACTIVITIES for a patient whose clinical condition(s) and interventions also are documented and qualify for the definition of a critical illness. Critical care time excludes the time spent in the performance of separately billable procedures (such as intubation, insertion of central line, insertion of thoracostomy tube, etc.)

The Bottom Line

Analysis of the aggregate services performed by a group of providers in an EM or HM program is essential for assuring adequate staffing levels, evaluating the quality of care, and collecting revenues for the practice. In terms of revenues, funds for physician compensation are primarily drawn from these revenues from the billing of professional services following analysis of medical record documentation and assignment of E&M and procedure codes by professionally trained coders and submission of a bill to third-party payers and patients.

Whether in solo or group practice, or working with a larger practice management organization, revenue should be based on the provision and accurate documentation of medically necessary services.

Jeff Slepin

Mark J. (Jeff) Slepin, MD, MBA, FACEP, joined EmCare in 2003 as the regional medical director for EmCare Physician Services (EPS), the EmCare division that manages rural, community and other small-volume hospitals and medical centers. Dr. Slepin is the medical director of NorthStar First Response, a Virginia-based company that provides basic and advanced life support training, as well as public access defibrillation programs for private and public entities. In addition, Dr. Slepin has served as a peer reviewer in emergency medicine for the Agency for Health Care Administration in the state of Florida.

John Coyle
John Coyle, DO, is Executive Vice President of EmCare Physician Services. Dr. Coyle graduated with honors with a Bachelor of Science degree in biology with a minor in sociology from St. Michael’s College in Winooski, Vt. He earned his doctoral degree from the University of New England College of Osteopathic Medicine in Biddeford, Maine. He completed his internship at Southeastern Medical Center in North Miami (Fla.) and later joined that organization’s Department of Emergency Medicine faculty. He completed his emergency medicine residency at Philadelphia College of Osteopathic Medicine. He has held senior management positions with several emergency management companies prior to joining EmCare in 2005.


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