Medical Staff e-Update

  • John Mogerman, MD

    Medical Director, Allegiance Behavioral Health & Chief of Staff

  • Ray King, MD

    Senior Vice President, Medical Affairs & CMO

Issue 13 - October 14, 2013

Friday, November 1 is the deadline for receiving the annual, mandatory influenza vaccination, as well as TB testing.

Approximately 18-months ago the CPOE i-Form for discharge instructions was developed.  The outputs from this i-Form are stored as orders and merged with any placed by another provider on a printed discharge instruction report.  Over the past year additional discharge ‘bundles’ have been abstracted from all available pre-printed discharge instruction forms and incorporated into the i-Form.  Anecdotal reports indicate that this along with on-line medication reconciliation decreases time to discharge by 30-45 minutes.  This method of providing discharge instructions is currently being utilized for nearly 2/3 of inpatient and observation visits.  As approved at the July 2013 Medical Executive Committee meeting, the i-Form will become the only approved method of providing discharge instructions for inpatient and observation visits as of November 4, 2013.  This does not currently include Day Surgery or OB Outpatient visits.

The Discharge instruction i-Form was developed with a number of time-saving features. 

  • By selecting the discharge ‘bundle’ at the top the i-Form fields are filled with the instructions abstracted from the corresponding pre-printed forms. 
  • Any field can be edited if not appropriate for that patient. 
  • Follow-up test or consultations as well as resource clinic referrals can be made from the i-Form. 
  • In several sections criteria can be easily applied to all items in the section i.e. timeframes for activity restrictions.

You can try out the i-form by clicking on the following link or typing/pasting the address into your browser:  If there are additional condition specific or clinical service specific discharge ‘bundles’ you would like to see added please contact Jon Sykes [517-780-7351,] or Nicole Templeton [517-788-4800, ext. 3430,].

In addition to streamlining the discharge process, the discharge instructions i-Form supports several initiatives including Core Measures and ARRA Meaningful Use.  Embedded in the Heart Failure, Unstable Angina/NSTEMI/STEMI and ischemic Stroke/TIA Discharge Instructions are prompts to capture approved contraindications to various recommended medications such as ACE-inhibitors, beta-blockers, aspirin, etc. For ARRA Meaningful Use Stage 1 we are required to provide an e-Copy of discharge instructions if requested.  For Stage 2 we are required to transmit an electronic document with a summary of the patients visit (including discharge instructions) to a patient portal and to the electronic medical record of the next provider of care. 

The CCDA or Consolidate Clinical Document Architecture document [formerly known as Continuity of Care Document] contains 15 elements including medications, allergies, problem list, procedures performed and discharge instructions.  The structure and coding of the document elements are designed to allow them to be incorporated into the database of an electronic health record or viewed in a Web browser.  Jackson Community Medical Record [JCMR] is currently deploying a patient portal, which we plan to leverage for patient communication.  Once upgraded to the Stage 2 certified platform, JCMR NextGen will be capable of viewing and/or ‘consuming’ the CCDA.  We are currently working with both McKesson and NextGen to develop this communication path.

The purpose of the Medical Records Delinquency Policy is to ensure documentation in the medical record is timely, complete and in compliance with medical staff rules and regulations, as well as, federal and state guidelines.  As a member of the medical staff of Allegiance Health, you have accepted the obligation to comply with the rules and regulations of the medical staff.
In order to comply more readily with the purpose, and enforce the requirements of the policy MEC approved revisions to the policy at the September 18, 2013 meeting.  The timeframes for completion have not changed but the monitoring of the process has changed.  A summary of the changes are noted below:

Delinquency List:

  • Combine the Suspension List (charts over 30 days) and the Delinquency List (charts less than 30 days) into one list – The Delinquency List which is generated daily. If a provider appears on the list they will not be allowed to admit or schedule procedures until charts are completed or they contact the AOC to request a 24 hour extension.

Monitoring and Reporting:

  • Increase the number of times a provider can appear on the Delinquency List prior to receiving notice of a rule violation to seven (7) days for the month.
  • Require the Clinical Service Chief (CSC) to be involved in the development of the provider’s performance improvement plan (PIP) at level 2. Failure to submit a PIP within 14 calendar days will automatically advance the provider to level 3 the following month.
  • At each level a notice of a rule violation will be forwarded to QMC for inclusion in the provider’s file.
  • Require at level 3 only the information of the rule violation be sent to MEC, the provider will not need to attend MEC. The violation will be made part of the provider’s credentialing file. MEC reserves the right to recommend any action deemed appropriate and will contact the provider of their action.
  • Expectation that charts will now be completed prior to vacation eliminating additional time upon return.
  • Currently there are many physicians at various levels in the process. The recommendation is that they all receive Letter 1 which will clearly explain the new process. This will start a new 12 month monitoring period for each of them.

We realize that these changes are significant, however to be compliant with our current Bylaws and Rules and Regulations, as well as, maintain our participation in the Medicare program, these changes must occur. 

We greatly appreciate your cooperation with these revisions.

Allegiance Health is pleased to welcome a new orthopaedic surgeon to our medical staff—Timothy Ekpo, DO.

Dr. Ekpo is a  graduate of the Lake Erie College of Osteopathic Medicine in Pennsylvania, He completed a combined internship and orthopaedic surgery residency training program at Genesys Regional Medical Center – Michigan State University in Grand Blanc, MI. Following his residency, Dr. Ekpo chose to pursue an additional year of subspecialty training in primary and complex revision of the hip and knee at Mount Carmel Hospital and Ohio State University.

Dr. Ekpo’s areas of expertise include:

  • Total knee or hip arthroplasty or total knee or hip replacement
  • Partial knee arthroplasty  or replacement
  • Patient matched /custom knee replacement
  • Reconstructive hip and knee surgery
  • Joint preservation surgery
  • Fracture care

Ondrea Bates, RN
Senior Vice President, Patient Care Continuum & Chief Nursing Officer

In this role, Ondrea will provide leadership and strategic direction for Adult Inpatient Care, Critical Care, and Women’s and Children’s Services. She will also oversee Emergency Care, as well as Home Care, Hospice and Chronic Care Services, and CareLink.

Ondrea most recently served as Administrator of Clinical Operations at Oakwood Heritage Hospital in Taylor, Michigan. 

Ondrea said, “The entire Allegiance team demonstrates a profound passion for health, caring and community. I look forward to being part of this exceptional organization.”

George Hunter
Vice President of Human Resources. 

In this role, George will provide valuable leadership and strategic insight for this key division, including Human Resources and Allegiance Health University.

George has accumulated nearly 30 years of human resource leadership experience in health care.  He brings expertise in benefits administration, human resource information and staff relations to our organization.  He most recently served as Vice President of Human Resources at Maine Medical Partners in Portland, Maine. 

“I appreciate the values and mission of Allegiance Health, and share your commitment to serving the health care needs of our community,” said George. “I am looking forward to becoming involved in the greater Jackson area.”

Allegiance Health has been certified through the Quality Oncology Practice Initiative® (QOPI). An affiliate of the American Society of Clinical Oncology, QOPI is a voluntary self-assessment and improvement program that helps hematology-oncology and medical oncology practices evaluate the quality of care they provide. QOPI Certification is awarded to cancer programs that meet or exceed national quality benchmarks and demonstrate commitment to quality care.

During the process for QOPI certification, Allegiance Health successfully completed an on-site review of policies and procedures that affect patient care and safety. Among the areas evaluated were chemotherapy preparation and administration, patient monitoring, patient education and emergency preparedness.

The Allegiance cancer program has also achieved full accreditation from the American College of Surgeons Commission on Cancer (CoC). According to the CoC, this accreditation is considered a “seal of approval” and a formal acknowledgment of Allegiance Health’s “commitment to providing high-quality cancer care to [its] community and patients with cancer.”

Congratulations to the Allegiance oncology physicians and their teams for these noteworthy achievements, which assure that our patients are receiving the highest level of cancer care.

Allegiance Health is pleased to welcome Independent Hospitalist Physicians, a new group of 16 full-time hospitalists who will focus on care coordination for our inpatients.  A hospitalist is a medical doctor who specializes in the care of hospitalized patients.

We are already benefitting from our partnerships with Independent Observation Physicians and Independent Emergency Physicians. The new hospitalists will communicate with care consultants, as well as primary care providers to ensure that our patients receive a smooth transition of care. They will also be involved in medical staff work groups to improve processes.

Welcome New Hospitalists

  • Jon Lake, MD , Medical Director
  • Bharath Chidamber Alamelumangapuram, MD 
  • Sumar Bhullar, MD   
  • Pauline Chiu, MD
  • Prasanth Gogineni, MD
  • Aruna Gollapalli, MD
  • Deepti Kamat, MD
  • Sonia Khan, MD
  • Quintadi Liu, MD
  • Padmaja Manne, MD
  • Rupali Paradkar, MD         
  • Danial Rashid, MD
  • Akhil Rahman, MD
  • Faisil Shah, MD
  • Harpreet Singh, MD 
  • Syed Tasleem, MD

At times, a physician may have the urge, or be asked by a family member, to report a patient’s medical condition or functional impairment to the Michigan Secretary of State’s Office,  because the patient’s condition could impact his/her ability to drive safely.

Until recently, Michigan law did not require or permit physicians to report a patient with a medical or physical condition that he/she believes could impact the patient’s ability to drive safely, except in rare instances when the physician’s examination of the patient was conducted specifically to assess the patient’s ability to drive and obtain or keep a driver’s license. 

In December 2012, Michigan passed a new law (MCL 333.5139), which allows a physician or optometrist to report a patient’s physical or mental condition to the Secretary of State (or warn a third party), that may impact a patient’s qualifications to drive safely, and could result in an ‘episode’ that jeopardizes the safety of other people or property.  An ‘episode’ is defined as:

  • An experience resulting from condition that causes or contribute to loss of consciousness, blackout, seizure, fainting spell, syncope or other impairment of the level of consciousness;
  •  An experience resulting from a condition that impairs an individual’s driving judgment; or
  •  An experience caused from impairment of an individual’s vision.

Although the new Michigan law makes it possible for physicians to make such a report, it does not mandate that such a report be made.  In other words, physicians have no “affirmative duty” to make such a report to the Secretary of State or provide a warning to third parties.  However, if a physician or optometrist voluntarily chooses to file a report, he/she must also make a recommendation to the Secretary of State about an appropriate period of time for license suspension (a minimum of six (6) months for an operator’s license, or twelve (12) months for a commercial driver’s license).  Page 2 of this bulletin is an example of the report form which may be filed with the Secretary of State).

Finally, under the new law, if a physician or optometrist, in good faith, chooses to report, or chooses not to report, he/she is immune from civil or criminal liability for filing the report, or for injuries to the patient or a third party which resulted from the actions of the patient.

Regardless of whether or not a report is filed, physicians and optometrists can still be liable to a third party for negligence if he/she knows about a patient’s physical or mental condition that could interfere with the patient’s ability to drive safely, but fails to provide appropriate treatment and education to the patient.  For example, a physician providing care to a patient who is being treated for drug or alcohol abuse should advise the patient that he/she should refrain from driving while intoxicated as his/her ability to drive safely is impaired and operating a motor vehicle could result in harm to the patient or a third party.  Physicians should clearly document any treatment and discussions with the patient, in the patient’s medical record.

The “two-midnight” rule, slated to go into effect on October 1, 2013 with the beginning of the new federal fiscal year, has had enforcement delayed until January 1, 2014; practitioners should begin documenting under these requirements as soon as possible to become familiar with federal expectations.  This rule requires that admitting practitioners’ documentation and admitting order include the following:

  • Severity of illness
  • Resources required
  • The exact language  “Expected stay of at least two midnights” for patients being admitted as inpatients; patients being admitted as observation status should have “expected stay of at least one midnight” documented by the provider
  • Date, time and signature

A patient’s time spent in the Emergency Department (ED) can be counted towards the two-midnight rules, as in the following example:

  • Patient presents to ED at approx. 10:45 p.m. on 1/1/2014 and is triaged, beginning immediate care by hospital staff. Hospitalist admits patient at 1:15 a.m. on 1/2/2014, documenting that “two midnights” of care are medically necessary.  The patient is discharged on 1/3/2014, having received care that spanned two midnights, as medically necessary.

Surgeons must have completed the admitting order for impatient care prior to a scheduled surgery, if it is anticipated that the surgery will be followed by an inpatient stay. It is the responsibility of the practitioner to document the medical necessity of the patient’s continued patient status on a daily basis.  Prior to discharge, the practitioner must have completely documented and certified the following:

  • Reason for inpatient services
  • Time required in hospital
  • Plans for post-hospital care

CMS will be reviewing 10 to 25 inpatient hospital claims spanning less than 2 midnights after admission that occur between October 1, 2013 and December 31, 2013 as a “probe sample” and providing non-punitive feedback on whether the two-midnight benchmark was correctly applied.  Additional guidance and education will be developed based on national performance of these probe sample reviews.

The Health Insurance Portability and Accountability Act (HIPAA), has new requirements which became effective on September 23, 2013.  These requirements include:

  • Updated Notice of Privacy Practices
  • Heightened Breach Analysis Requirements
  • Additional Business Associate (BA) Responsibilities
  • Documented Risk Analysis of Electronic Record Systems
  • Shortened Response Time to Patient Record Requests

The Office of Civil Rights (OCR), the federal entity responsible for administering HIPAA, has developed education and materials for providers’ use to assist in your implementation of these requirements:

A free Continuing Medical Education (CME) .5 Category 1 credit created by OCR is available at the following link, hosted by Medscape:


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