Mitchell H. Tsai

The use of Twitter to facilitate sharing of clinical expertise in urology

The use of social media in the urologic community is common and increasing. Although the potential benefits of platforms like Twitter have been described in the literature, the use of social media in the clinical context of Urology has not been explored.In this case report, we describe how we used Twitter to share ideas about the clinical management of a complex urologic patient. By posting a clinical scenario, a timely discussion was generated with global participation and expert suggestions. This knowledge was applied to the surgical management of a patient with positive clinical outcomes.The ability of Twitter to facilitate rapid communication with a wide network of contributors makes it a potentially useful tool for clinical decision making. Care must be taken to ensure patient confidentiality and caution used appropriately when evaluating the sources and content of the clinical information shared.

Scheduling non-operating room anesthesia cases in endoscopy: Using the sandbox analogy

STUDY OBJECTIVE For many hospitals, the non-operating room anesthesia (NORA) workload continues to expand. We developed a new NORA scheduling process with shared block time - a sandbox - amongst all of the gastroenterology groups and measured the efficacy of the intervention using basic operating room management metrics. DESIGN Prospective analysis, statistical process control. SETTING Academic, rural hospital; endoscopy suite; postoperative recovery area. PATIENTS Adults and pediatric patients undergoing elective and/or urgent endoscopic procedures. INTERVENTIONS In 2014, we divided the NORA block allocations on Thursdays into one afternoon block for pediatric GI, and 1.5 blocks to be shared between the two adult GI groups. We made a provision for an additional afternoon block available if necessary. No changes were made in the release policy. For scheduling, shared block time was released between the three endoscopy groups at 7days and then opened to the general pool at 48h. MEASUREMENTS Case volumes, under-utilized time (opportunity-unused), elective time-in-block, over-utilized time. MAIN RESULTS With the addition of a pediatric gastroenterologist, the number of cases per month increased after the change in scheduling procedure from a mean of 107 cases per month to 131, an increase of 23% (p=<0.01) (see Chart 1). Elective time-in-block increased after the intervention by 13% (p=0.09), while under-utilized time (opportunity-unused time) decreased in a reciprocal fashion (15%, p=0.03). Pre-intervention mean over-utilized time was 101min/month, while post-intervention over-utilized time decreased by 84.5% (99% CI ±3.29) to a mean of 16min/month. CONCLUSIONS By using a multi-disciplinary, team-based approach, we were able to increase throughput without increasing under-utilized or over-utilized time, thereby increasing efficiency. Despite the additional cases brought in by the pediatric gastroenterologist, opportunity-unused time decreased only moderately-lending support to our prediction that opening an additional NORA block was not only unnecessary to accommodate expansion of the gastroenterology service, but was also financially unviable. One of the challenges in reducing under-utilized time lies in the relatively new role played by anesthesia in the NORA environment. In our study, we showed that the open access policy applies when the block allocations have under-utilized time. As anesthesiologists continue to expand their practice into the NORA environment, good communication, interdepartmental collaboration, and flexible scheduling processes are essential to improving efficiency.

Observations: clinical revenue directly attributable to anesthesiology residents.

During the graduate medical education reform of the 1990s, anesthesiology programs across the country downsized to accommodate a perceived oversupply of anesthesiologists in the marketplace and to make room for an additional number of training positions in the primary care residencies.1 As academic programs struggled to work more efficiently either with replacement of clinical staff members or with different staffing models, many programs experienced an increase in their operational costs because of a reduction of their labor force and a discrepancy in anesthesiology billing practices.2,3 Prior to 2011, the Centers for Medicare and Medicaid Services (CMS) and many private insurance companies reimbursed anesthesiology programs at a 50% discount. Today, academic anesthesiology programs have been able to bill for 100% of the services provided, regardless of staffing ratios.4 We examined the revenue stream directly generated by the clinical activities of anesthesiology residents at our program during the time period July 1, 2011, through June 30, 2012, and demonstrated that our entire residency program delivered 4664 billable anesthetics, billed for

The hidden cost of variability.

7,892,558, and collected

Ten Tips in Providing Value in Operating Room Management

2,802,969 in total payments. We determined that direct costs for an anesthesiology resident by clinical training year, including salary and fringe benefits for Clinical Anesthesia year 1 (CA-1), CA-2, and CA-3, were

The Association of Anesthesia Clinical Directors (AACD) Glossary of Times Used for Scheduling and Monitoring of Diagnostic and Therapeutic Procedures

65,951,

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures

71,492, and

Electroconvulsive Therapy Considerations for Transgendered Patients

75,636, respectively. With a total cost of nearly

Building a value-based platform.

1,300,000 for our residency, we estimate that the direct revenue attributable to the anesthesiology residents is

Perforation of the right atrium during radiofrequency catheter ablation.

1,500,000. There are several limitations to our analysis. First, the applicability of this methodology to other institutions may be limited for academic programs with different staffing models. Our methodology only accounts for the differences in billing when residents are staffed at 1∶1 versus 1∶2 ratios, and we show differences between the various classes in the subgroup analyses. Second, our academic program uses both a web-based scheduling program (OpenTempo, Richmond, VT) and an electronic billing service (PAR Management, Newton, MA). Academic programs without similar services may find it difficult to accurately track the revenue stream attributable to anesthesiology residents. Third, across the country, each training program faces a different payer mix, which affects the reimbursement rates for clinical activities. Finally, we do not account for the indirect costs of training residents (eg, academic time to prepare lectures, teaching time in the operating room, assistant residents in research projects). For instance, using a survey method, Kelly et al5 estimated that the “hidden” costs average