session of transforming healthcare practice, navigating Medicare changes, scope of practice, and workforce strategies for APPs. In today's economical times, I believe it becomes more and more important that APPs are getting more and more empowered and integrated in the management of patients with arrhythmias and this session is basically aimed to point out reimbursement opportunities we are having, how we can train and keep staff basically in our facilities. Yeah, I think that's the major goal of this session. By the way, my name is Madeline Oster, I'm a nurse practitioner at Stanford and I work in the in and outpatient services. Welcome everyone, I'm Jill Schaefer and with that, we're going to get started with our first speaker, Erika Zato. She's going to review the 2024 Medicare rule change for split shared billing and the impact on reimbursement, staffing, and collaborations. Take it away, Erika. Thank you everybody and thank you for coming. Waiting for booting up. My disclosures, which I have none other than as much as I know about billing is what I've been told by my billing compliance people and they were very, our one billing compliance person, Carol Pollack was very helpful in helping me do this talk. So, I want to start with some questions for the audience just so I know who you are and what you, not even what you know, but who you are to guide this a little bit. So, raise your hand if you're an allied, an APP, which I'm assuming everybody is since that's the topic here. Raise your hand if you're required to generate RVUs. Qualifier, if you don't know what an RVU is, you don't need to generate them because they would have told you. Raise your hand if you see patients independently in clinic. So, good, about half people. Raise your hand if you perceive that split shared billing model affects you adversely. Okay. Raise your hand if billing confuses the heck out of you. I think that's purposeful, but that's, there's, just me. So, what is split shared billing or shared split billing depending on what you Google? So, basically, it's when an APP or, and a physician see, basically see a patient together and perform a single evaluation and management service basically on the same day. So, you're going, you see the patient, the doctor goes, sees the patient. The billing for that visit is done based on who did the substantive portion of the visit based on either the time spent or medical decision making. So, there's some qualifiers to all this as there always are. So, you have to be part of the same practice. You must clearly document, this is gonna come up over and over again, which practitioner did which part of the visit, the time spent, who made the medical decisions or the majority of the medical decisions. And obviously, this is all really hard to parse out. And this only applies to facility settings. So, clinics attached to facilities, emergency rooms, outpatient, inpatient practices, inpatient services, et cetera. Incident two, there's a separate sort of pathway. Incident two billing is like private practice. So, if you're in a private practice, in an office detached from the hospital setting, that's incident two. And I have a slide on that because it is different. So, it's a different paradigm. So, some more qualifiers. There's now a modifier that you have to attach to the visit, which is FS. And a lot of the EMRs now make this easy to do. This basically improves transparency for the coders and for frankly, Medicare. This is Medicare patients only. Or it's a Medicare rule, CMS rule. But a lot of private insurances, commercial insurances, use the same rules and bill under the same rules as Medicare does. So, you sort of need to know this. And frankly, who's gonna look at the patient, you know, insurance information when you're clicking your boxes to bill people? If you have that as part of your job, you know, you're not gonna sit there and go, oh, this person's, you know, UnitedHealthcare. I can bill a different level or whatever. Just bill the same way. And then the biggest thing which impacts us is physicians are always reimbursed at 100% as APPs where we bill 80, you know, they get reimbursed at 85% of that same code. So, just really quickly, you don't have to memorize this. When you are doing a time-based, again, time-based billing, you have to see the patient in conjunction with the physician for a certain amount of time. So, for established visits, it's 40 minute, you know, to get the highest billing code, it's 40 minutes and lesser numbers for other things. And then, you know, again, this is from my coding manager, documentation manager, she's amazing. So, and you don't have to memorize, well, you do have to memorize these. Like, if you wanna bill at the highest level for time, you have to spend at least 40 minutes, you know, in that day and where there's important qualifiers for this as well. Hold on. Because what does time mean? Like, that's not 40 minutes in front of the patient doing your stuff, it's a lot of things. And that's preparing to see the patient, obtaining their history, you know, these are things that we do automatically. Performing the exam, doing your teaching, doing, ordering tests, ordering medicines, talking to other doctors if you have to, and most importantly, documenting this. You, again, have to document it. And the, and then, you know, independently interpret other results and things like that, care coordination, all this stuff. That all accounts as time spent with the time spent on that visit. And again, the important thing is, sorry, keep clicking the wrong button. The, and I'll go back to this, the time that, this time does not include, and this is important for us, your device interrogation or interpretation of those results. So those are, that's an independent service. So you can't in your, if you're, again, billing it for, you know, 40 minutes or whatever, that does not include your interrogation. It also doesn't include you looking at and interpreting the EKG. That's separately billed. So, but it also doesn't include travel. It doesn't include sort of general teaching. You know, if you're not teaching about, like, what you're seeing the patient for. And it doesn't include your staff's time, your MAs, your admin staff, things like that. So, but the important things for using time for shared split billing is the, it's only time spent on that calendar day. So a lot of those activities, frankly, we do, like, on other days, you know, if you're finishing your notes or whatever on other days, like, that time is not counted in that time, if you're billing based on time and your time, you know, time spent with that patient on that day. So, and remember that, you know, like, frankly, if you get audited and they see that you, you know, did all this before or after that calendar day, they can see that because there's timestamps within your electronic medical record. And also, a lot of that stuff that you're doing, like, for a patient is, you know, basically unbillable because it's, you know, like, you're doing that on another day. Like, say that patient you saw and billed for that day on that visit, you know, gets to ablation a month later. Like, a lot of that, like, review and all this, there's more tests that came in, things like that, that you're doing that's sort of unbilled. So, you just have to kind of keep that in mind as, like, your value to the practice, you know, because, again, you know, if you have an administrator that's looking at, like, this is how many RVUs you generated, this is how much time you, you know, was spent that, you know, like, that's uncounted for. We always have to think about that when administrators are coming at us going, well, what do you do all day? It's like, well, let me show you. It's like, I know it's not billed, but I'm doing it. So, there you go, just because they're not paying for it. But the, so it's basically only time on that calendar day that you can bill for that visit. It's, you have to document how much time you spent, and again, keep all that stuff in mind. It's not just, like, how much time you spent in front of the patient and examining the patient. It's, like, reviewing things, preparing your note, and whatever, and then the physician, if you're gonna bill under the, is the physician, basically, he has to, he or she has to say that they did the substantive portion. So, more than half of that time, whatever you're billing for, has, they have to document that they spent more time than you did to get the 100% reimbursement versus the 85% reimbursement. So, and then this is made easier by, you know, again, in electronic medical records have dot phrases, you know, that says, like, this is how much time I spent, this is how much time they spent, you know, this is what Penn, you know, they, you know, gave us smart phrases to use and that thing. And they, so they can easily document, you know, the time spent if you're billing it based on time. And doing, billing based on medical decision-making, again, is very, is easier, harder, but the pitch that I wanna make is that, like, again, I think we undervalue ourselves because, and I'm saying this to my colleagues at Penn all the time, like, you know, you're seeing a patient and it's a routine patient, but that person's on amiodarone or dofetilide or an anticoagulant that requires that you follow some tests or, you know, and that you're checking, you know, you're checking X, Y, and Z. And, or they have an exacerbation of a problem. We, not infrequently, should be billing at a higher, like, you know, coding at a higher level than we are. And all our patients, even the routine patients, the vast majority of them have five different medical problems that, I know we say we're not following, but we really are, because we're taking all of that into consideration in our care of that patient. Document that, make sure you're, you know, that you, everything is clearly documented and you can, and you basically can build a higher level. And again, if it, whether you're, it's being billed under you or billed under the physician, it's still being billed at a higher level than you probably think it should be, because you're like, oh, this is just a routine patient with a routine follow-up. I mean, again, there's, there are the patients, the well baby visits, as I've heard a couple people say this already this meeting, you know, where they're just coming in, they're getting their device checked and, you know, and, you know, you're kind of going, okay, everything's great, move on. But most of our patients actually are much more complex than that. So keep that in mind when you're, and none of us like to think about, you know, billing and whatever, but, you know, check all the boxes, like these people have problems. Just for those people that are private practice, do you typically billing under, if you're seeing patients with a physician, you're billing incident to billing, which basically allows APPs to bill certain services under supervising physician's MPI. So you're getting a hundred percent. So that physician's probably getting the RVUs, that physician maybe, but that physician has had to have seen the patient first, not the same time, but previously set a plan. And you're basically, so the example is somebody with AFib, physician has seen them, they're on anticoagulation, they're on their Sotolol, you're seeing them six months later, everything's great, whatever, that you can bill at a hundred percent, like again, the practice can bill a hundred percent under the physician with you doing the work. So that may go away. Anyway, just quickly, when this came about January 2024, but of course the rules were made back in 2022 and 2023, before they were put into practice, literally one, I could find one paper because they wanted me to talk about how this impacts us, there's no data. But there was a paper, they did a survey, it was a small survey, and what was the concern about split shared billing. And I'm not sure any of this came to pass, and the fact that nobody raised their hand is like, are you worried about this adversely affecting you? Like people initially apparently were worried that we would be in competition with physicians, we'd be, you know, like battling for our views, we'd be, you know, it would affect patient care because of this competition. I don't feel like any of that has happened. But this is the most important part in my final slide. Basically, shared split billing and independent APP run clinics, like could theoretically lead to reduced revenue, because again, we're billing 85% versus 100%. You know, so, you know, if you have an administrator who's like worried about that 15%, you know, it's a problem. The thing is that this can be mitigated by allowing physicians to do other things that generate far more our views and more money, frankly. And then an APP working at the top of their license is an invaluable commodity, and we have to keep reinforcing this, both obviously in taking care, you know, promoting excellent care. I mean, that's what we do. But also as a teammate to a lot of the physicians, they don't want to be answering those phone calls, they don't want to be like, you know, spending endless hours documenting, they don't want to be handholding, they don't want to do that. And frankly, they don't have the time. Like by having us around, then they can go do their devices, they can go do their ablations, they can go do their, you know, watchments, et cetera. So like having us around is, it sets time aside for them to safely and effectively perform like real revenue generating procedures. So with that, I'll end. This is our mothership, literally. And we'll be taking questions, I believe, after the speakers. Thank you. I would like to remind everybody that we have the QR code. If you have any questions during the presentation, that you can please submit a question, and we will try to answer them at the end of all three presentations. And next we will, Lindsay actually will talk about defining the scope of practice for reduced and restricted authority, since we still have differences in the US. And she will answer the question, where do we stand and where do we need to go from here? Thank you. Good morning, everyone. Again, my name's Lindsay Harris. I'm a nurse practitioner at Brigham and Women's Hospital in Boston, Massachusetts. I work in an outpatient EP clinic there. I'm also the senior director for advanced practice nursing there at the Brigham. And scope of practice is certainly something that comes up in my day-to-day and our day-to-day. And I think it's a wonderful complement to what we just talked about with Erica. And I will try to chain myself to this podium because I tend to wander away from the microphone when I'm talking. So where do we stand and what do we need on APP scope of practice? Well, the content for today, we're going to focus mainly on two of the professions included in the advanced practice provider umbrella. We're going to focus on nurse practitioners and physician associates. And if I mistakenly refer to my physician associate colleagues as physician assistants throughout this talk, I apologize. It rolls right off the tongue. It is not on purpose. We know that the US is facing a significant shortage of health care providers, most notably primary care providers. And there is considerable potential for APPs to mitigate some of these access problems associated with the shortage. According to the US Bureau of Labor Statistics, from the decade of 2012 to 2021, our APP workforce increased by over 94% compared to a 19% increase in our physician colleagues. There's also an estimate that by 2029, nurse practitioners and physician associates will represent approximately 30% of the health care provider workforce. And driven by the need to improve access to care, many states have enacted laws liberalizing APP scope of practice. With that said, in some areas, these efforts have been met with significant resistance due to longstanding concerns about quality, safety, which all of these may confine the role that APPs are permitted to play. And today, we're going to examine some of the debate and the data surrounding expanding APP scope of practice. And what does that mean? I think there's a lot of sometimes negative connotations when we talk about expanding APP scope of practice. But what are we actually speaking about? And the elements of scope of practice include the ability to diagnose, evaluate, order and interpret diagnostic testing, and manage treatments, including prescribing medications and controlled substances. I also want to be clear in what I mean when I talk about top of license. That's another term that's thrown around a lot and can have some connotations. Top of license can apply to any health care provider, actually. And really what I think a solid definition of top of license is performing the full scope of clinical duties and decision making that education, training, certification, and licensure will legally allow. And where do we stand across the US from a scope of practice perspective? Well, for nurse practitioners, according to the American Association of Nurse Practitioners, as of October 2024 anyway, there's about 27 states, including Washington DC, that have full practice authority. And what that means is that a nurse practitioner can perform those elements of scope of practice without restriction independently under the exclusive licensure and authority of the State Board of Nursing. There are also states that have reduced practice or restricted practice. And what that means is that at least one of those elements are reduced or restricted. Some examples of that might be dispensing medications. A number of supply that you can provide on certain medications might be reduced or restricted. Some states might also dictate, state laws might also dictate what type of diagnostic and radiology testing may be ordered by a nurse practitioner and that those testing results need to be reviewed by a physician. Our physician associate colleagues also have categories outlining their scope of practice that align pretty well with our nurse practitioner scope of practice landscape. They have optimal, advanced, moderate, and reduced. And as of 2025, I believe there are six states that have optimal practice. And that correlates most closely to what nurse practitioners would call full practice authority. But again, there are many states that remain with moderate or reduced practice. And some examples of that might be the inability to sign death certificates, inability to sign disability forms, order co-signatures are required. There's also states that dictate the number of physician associates that a physician can actually supervise. And even in some states, a physician has to apply to the state to be a supervising physician for physician associates. And you may ask, well, what's the big deal? But this bureaucracy, we know, can delay and negatively impact patient care, which is why there are efforts to liberalize scope of practice across the country. And what are the key considerations? So when we're thinking about this, what are we considering? We're considering, of course, state regulations and licensure. Each state independently defines scope of practice for advanced practice providers. Our collaboration agreements and supervision, which are contracts with the supervising or collaborating physicians that are legally mandated. Billing and reimbursement, as Erica just shared, in many states requiring supervision, billing may need to flow through a physician first, versus an APP billing under their own NPI. Their prescriptive authority, controlled substances, and ability to prescribe varies by state. Professional liability, this comes up a lot. The level of independence impacts malpractice risks and coverage needs. Access to care and rural health, expanding APP practice has actually been shown to expand access to care in underserved areas. Credentialing and privileging, the legal authority does not automatically dictate health care systems or payer policies. So this is actually applicable in my home state of Massachusetts that enacted full practice authority for nurse practitioners in 2021, but our health care system has not yet adopted full practice authority across the board. We're starting slowly. We're considering a slow rollout at some of the smaller community hospitals, kind of testing the waters, but we have not expanded to our academic medical centers yet. And advocacy and policy engagement. So professional organizations like the AANP and AAPA continue to advocate for scope of practice modernization that align with evidence based care delivery models. And I think sometimes these conversations are framed as an APP versus physician debate. And I really, by the end of this talk, want to move away from that narrative because the real opportunity is how we work together to better serve patients in this rapidly evolving health care landscape that we share. And what is some of that debate that surrounds APP scope of practice? We certainly have some pros, but some of the concerns related to modernization focus on patient safety, training differences, care quality, and coordination. So from an access to care perspective, data has shown that expanding APP scope of practice empowers more providers to deliver care in underserved areas. Though a concern is that APPs may not be equipped to care in resource limited areas. APPs provide comparable outcomes in primary and chronic care management, but there's concerns about missed or delayed diagnoses in complex cases. We have no evidence of reduced safety in states that have enacted full practice authority, but there's also a thought that physician oversight could ensure added layer of clinical judgment and assurance. Voluntary collaboration still thrives without legal mandates. Scope of practice expansion and modernization does not prevent collaboration with our physician colleagues. Mandatory agreements ensure communication and oversight, and separating physicians from APP teams may lead to fragmented care. High quality and cost effective care has been provided and is provided by APPs on a daily basis. There is also some data, though, it's minimal, but it shows that APPs may over-refer, over-test, and over-utilize services, which of course could increase the cost of care. And then clarity. Modernizing and liberalizing APP scope of practice aligns licensure and reduces administrative burden that can lead to delays in care, though there is a concern that differences in APP program quality and clinical rigor exist. So what does the data show? And I also want to share that I use the term full practice authority a lot, which does apply to nurse practitioners. And part of that, the data is slightly skewed in that there is more data out there that I have been able to find on full practice authority, but that's because we have a larger, there's 27 states as opposed to the six states for our physician associate colleagues that have enacted optimal practice. So there's just more states that have full practice. So there's a little more data out there about the impact of quote, unquote, full practice authority, which primarily refers to our nurse practitioners. And so to answer the question about prescriptive practice in patient safety, for example, Stanford actually conducted a retrospective review looking at 73,000 providers, nurse practitioners and physicians or primary care providers. And they analyzed their prescribing patterns in states that had full practice authority. So the question was, does the safety or appropriateness of NP prescribing fall short? And they defined inappropriate prescribing according to the BEERS criteria. So they focused on an older population. They used Medicare data, the American Geriatric Society qualification. They adjusted for provider gender, years of practice, volume, patient risk score, practice setting, location, and date. You can see here that the adjusted rates of inappropriate prescribing were not statistically significant, 1.66 to 1.68. And the authors stated that nurse practitioners were no more likely than physicians to inappropriately prescribe to older patients. However, broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive practice authority to APPs. So really considering the health care provider population as a whole and elevating us all rather than kind of pushing down or stopping one group from moving forward. Then some data on diagnostics and cost of care. So do APPs order more imaging? This was a retrospective kind of primary outcome whether or not an imaging event followed a qualifying E&M visit. The authors looked at a 5% sample of Medicare claims between 2010 and 2011, comparing diagnostic imaging ordering between an APP and a PCP. APPs are, in this article, they use the abbreviation APC, which is Advanced Practice Clinician. You might see that out there somewhere. They were associated with more imaging than PCPs. They ordered 0.3% more images per visit or per episode. It is important to note, though, that the authors did not look into the appropriateness of the imaging, just the amount. So they did not take a deep dive into the appropriateness of the imaging, just that there was, in fact, more imaging associated with a visit with an advanced practice provider. And so while we cannot discern, this is from the authors, while we cannot discern whether the differential in ordering represents an overuse by APCs rather than an underuse by PCPs, efforts to expand access to care by simply substituting APPs for physicians without careful imaging appropriateness mechanisms may further elevate health care costs and potentially increase unnecessary radiation exposure. And I put that quote up there, one, because it also highlights that they did not necessarily evaluate the appropriateness of the ordering. But I think it also speaks to this kind of growing narrative, like this us versus them, that concern that health care systems will simply replace physicians with APPs. And that is not the point. That is not the point of the expansion of APP scope of practice that is a narrative that I think we need to move away from as a population. Another concern is if we liberalize APP scope of practice, will malpractice claims go up? Will there be more malpractice? That means that nurse practitioners and physicians associates should be carrying their own malpractice insurance, of course. This is an analysis from Candelo, which is a subdivision of Crico, looked at more than 5,600 malpractice cases and found that despite increasing proportion of APPs and the fact that they are caring for certainly a more diverse and complex patient population, their share of malpractice burden has not shown an equivalent shift. And that was looking at data from 2012 to 2021. And access to care, this is another important consideration when we're thinking about liberalizing APP scope of practice. A couple reviews here are looking at before and after implementing full practice authority among nurse practitioners in 10 states. This was published in 2020 and found that NPs are more likely to locate in a primary care provider shortage area in states that have implemented full practice authority for nurse practitioners than in restricted or reduced practice states. So they are going to areas with the expansion of full practice in these 10 states that they look at. The nurse practitioners were relocating to health care provider shortage areas, more so in states that did not have full practice authority. The second article looked at 50 states from 2010 to 2026. And they looked at the supply of primary care nurse practitioners, which significantly increased, particularly in low income and rural areas. So suggesting that NPs are increasingly filling primary care gaps in underserved communities. And then optimal use and collaboration. So this is actually an article that was a single sender retrospective review from California, which is not a full practice or optimal practice state, but looked at the impact of top of license practice in an outpatient setting for APPs, so both physicians assistants and nurse practitioners. So APPs working at the top of their license, seeing patients independently in clinic. And what they found was that overall RVUs increased by 53%, completed visits increased by 45%, 78% of APPs reported always or most of the time working at the top of their license. And highlighting here that there was no adverse impact on physician RVUs. So again, this was a small single center retrospective. But what they found when they expanded APP scope of practice just in their own setting and had both physicians and nurse practitioners and physician associates working at the top of their license, there was no adverse impact on physician RVU. And physician satisfaction remained stable. So what do we need going forward? I think it's really important for all of us to acknowledge the complexity of utilization of advanced practice providers. There is no one size fits all model. What works for an ambulatory surgery center is going to be different from an academic medical center. It's going to be different from an EP lab. And it's going to be different from a rural health care shortage area. I think we need to ground our decisions in evidence. We do need more data at the macro and micro level. Though what we have so far has shown that APPs consistently provide safe care despite the expansion of our scope of practice. Collaborative care models without legal mandates. Again, scope of practice expansion and physician collaboration are not mutually exclusive. We need to advocate for patient centered policy and foster environments where APPs and physicians engage in open dialogue around their roles, clinical boundaries, and care plans. And we really need to change the narrative. APPs are not physicians. They practice within their own education, certification, and licensure to complement and not replace physician practice. So finally, just to bring it home, research supports APPs practicing to the full extent of their education, certification, and licensure. Expanding APP scope of practice and physician collaboration are not mutually exclusive. We can do that together. And health care is at its safest when there's a commitment to shared values and everyone caring for the patient understands their role. Teamwork, not legal mandates, should drive health care innovation and build system resistance. That's it. Thank you. Hello and thank you for joining us this morning. I'm Angela Sipperfall, a nurse practitioner with Stanford Arrhythmia Service. Okay. I have brought some notes because I tend to get excited and carried away, so forgive me if I look at my notes. But I think we're all here because we encounter a challenge in recruiting qualified EP APPs, those who can practice to the top of their licensure in this complex field. And training these APPs is demanding, requiring significant time and resources. So I am here to present a well structured program or approach to recruiting and incentivizing advanced practice providers within the APP fellowship program that can significantly enhance our appeal to potential candidates while also improving retention rates. So I'd like to share our institution's experience with APP fellowship transition to practice program as a practical solution to address these challenges. So Sanford HealthCare is an academic medical center with 610 licensed beds with substantial resources, including nearly 2,000 medical staff, 850 interns and residents, 1,500 nurses, and a dedicated center for advanced practice led by a VP of advanced practice. Our APP workforce has extended or expanded by over 200% in the last decade and currently consists of more than 900 APPs. We're proud to operate six centers of excellence that are cancer care, cardiovascular health, neurosciences, orthopedic surgery, surgical services, and transplantation. Each center requires highly specialized care, underscoring the necessity for trained, highly trained APPs who can meet these needs effectively. Given our diverse and specialized clinical expertise and landscape, there's growing need for APPs with specific expertise and experience. However, finding the experienced providers is increasingly challenging, which makes on-site training not just beneficial but essential. Stanford Fellowship Program was developed to provide foundational training for newly graduated APPs or new to specialty APPs. It launched in 2016 with a focus on cancer care as the initial specialty and in 2018 it was expanded to include cardiovascular surgery fellowship, making it the first of a kind in the U.S. In 19, we introduced the administration fellowship, which was another pioneering specialty in the nation. Electrophysiology was the third clinical specialty to be added in 2021 and the first in this specialty in the country. In 2023, we added inpatient neurosciences and this year we added orthopedics. I just want to point out that our program is a result of collaboration between the Center for Advanced Practice, Center for Education and Development, Professional Development, and specialty service lines. The APP Fellowship Program at Stanford is now fully accredited transition to practice program for advanced practice provider fellowship accreditation or APPFA. We earned that accreditation and were given it this past February. We received this accreditation with distinction actually, which made the EP specialty the first specialty in the country to receive this certification. The program success is highly attributed to strong institutional support. This support has been essential to development and sustainability of our program. The program has very high visibility within the institution and that is, I believe, reflected in our supporting structure. Program leadership includes the APP Fellowship Program Director. This person oversees the program. The Fellowship Director reports to the Chief Advanced Practice Officer and in turn Senior Vice President of Patient Care Services. The Director of the program is responsible for overall orientation and training of all individual included in a program or involved in a program. The program leadership consists of program director and specialty leaders. The leadership team is responsible for program planning, decision-making, and continuous evaluation. This team ensures alignment and organizational goals and adaptability to current health care trends. Each specialty consists of a specialty leader, physician leader, who is usually a champion, we call them, is an experienced physician within specialty, often the chief of service or specialty medical director. This person articulates the value of APP Fellowship within the medical staff, serves as clinical expert and specialty in our specialty practice, and collaborates with program director and specialty leader to provide clinical decision and education. They also facilitate access to interprofessional groups and quality improvement projects. The primary preceptor is sort of a person with, there are boots on the ground, that's someone with at least one year of experience in practice who, like this specialty leader, is required to practice and complete the SHC preceptor course. They collaborate with program director and specialty leader to provide clinical guidance and education and play a crucial role in facilitating the clinical development of APP Fellow by offering opportunities to enhance their hands-on experiences and clinical reasoning. A specialty advisor group includes physician champion, primary preceptors, clinical leaders, management, alumni, APPs, and current APP fellows. The advisory group meets every four months to provide feedback to the program and guide specialty training initiatives. We introduced the APP role at EP service at Stanford in 2007. From the beginning, we recognized the significance of promoting independent and top of the licensure practice. And we take pride in the fact that APPs and AP have been practicing autonomously from the very beginning. I have to contribute that success and support to APPs to our chief, Dr. Paul Wong. He set that culture for our service and I am proud to say that we've initiated and maintained that culture, which probably was one of the pioneering practices at the whole institution. We recognize the need for extensive training from the beginning and we recognize the complexities that were inherent in AP practice to enable our APPs to meet the expectations for competent and independent practice. So over the years, we hired 16 APPs in six clinical roles, essentially. Outpatient, over time, we've separated these roles. So outpatient is a totally separate, independent group that manages patients in clinic. They are practicing completely independently with very few exceptions of shared or split-shared visits for new patients. They each have six new patient visits a week in addition to return patient visits. And then the other eight APPs are in this inpatient group and their roles vary or rotate on a daily basis. There's a role assigned, or APP assigned to inpatient role. CID consults, we have a pager that goes on a daily basis off any time a patient needs a consult in the ED or critical care areas and the one of us will go upstairs and provide essentially a consult and recommendations for patients who have CIDs. One person is assigned to cardioversion service. One person is assigned to MRI support. One person is assigned to peri-procedural support which includes managing patients before procedure, making sure that the consent is ready and the HMP is ready and labs are looked at and patients have all their questions answered. And finally, the lab support. This role is still under development but we're hoping to train someone to assist in the procedures. So recognizing the rigorous training necessary for advanced practice providers to competently and independently practice within the EP specialty along with the challenges of finding trained providers and time needed to develop competent practitioners, we drew inspiration from the established and successful models and specialties within Stanford APP fellowship programs like cancer care and cardiothoracic surgery fellowship to facilitate the inclusion of EP in our fellowship program. We formed the leadership team, completed the curricular development and identified and trained preceptors. After rigorous application process, EP was added to the program in 2021. It was added or chosen for its high clinical standards of practice and available resources to support the fellowship. We needed to have enough APPs to be able to train APPs that are coming on. So APP fellowship program offers 12 month paid and fully benefited positions and serves as a transition to practice program that is centered on three main domains. Role transition, professionalism and acquisition of specialty knowledge and skills. Each year, the programs hires one to three new graduate APPs with less than one year of clinical experience per specialty. There's also an administrative fellowship for experienced APPs who are changing their clinical practice to transition to a leadership role. The program centers around three primary learning approaches. The first approach is practice-based learning with a minimum of 1,250 hours of active, hands-on and observed learning experiences. The second approach is weekly didactic learning with 500 plus hours dedicated to various specialty-specific education activities including presentations, self-learning modules, journal club, simulated learning for high-fidelity, low-frequency clinical situations, case studies, project training and presentation guidelines. So the third domain is professional development. APP fellows enhance in communication skills through specialized communication series. They attend APP Grand Rounds and APP Shared Leadership Council. There are expected to submit abstract presentation and attend a conference as part of their professional development. It is crucial for APPs to learn how to design and conduct quality improvement projects. So they are trained to identify gaps in healthcare and expected to come up with a quality improvement project with a goal to implement practice change that ensures safe, high quality and sustainable patient care. Our curriculum was designed based on the established APP Fellowship Program blueprint. It includes methods to effectively deliver the content related to specialty and evaluate information received. We utilize the most current published guidelines for their specialty that includes the 2020 ACC Clinical Competencies for Nurse Practitioners, Physical Assistants and Adult Cardiovascular Medicine that includes EP care. Allied Professional Educational Competencies developed by the Council of Allied Professionals for the Heart Rhythm Society and the 2021 HRS Educational Framework for Clinical Cardiac Electrophysiology. During curriculum development, we identified two essential skills that are necessary for the specialty and that is EKG interpretation and management of cardiac implantable electronic devices. So the program utilizes the Dr. Tullo's EKG Academy course that is accredited by American Association of Nurse Practitioners and approved for both nurse practitioners and physician assistants. And by the end of the fellowship, APP Fellows are expected to learn certification in EKG interpretation from the AANP. And mastering management of cardiac devices is, as you know, challenging. We expect fellows to enroll in Medtronic Academy self-study modes. There are ongoing workshops. It was one of our CCDS certified APPs, happened to be Natalie. And there's hands-on training with inpatient and outpatient device experts. This is an example of what our curriculum looks like and what our rotations look like. So they have six weeks rotations in inpatient EP, outpatient EP, cardioversions with expectation to obtain privileges by the end of the fellowship program. Peri-procedural management. And this year we added two new core rotations which we believe are essential to the curriculum and that is in non-invasive cardiology and inpatient heart failure management. There are also menial rotations that are relevant to clinical practice. This is just an example of weekly readings that fellows are expected to do. And that includes links or assigned book chapters, links to most recent clinical guidelines and assignments for EKG Academy and Medtronic Academy. This is just an example of didactic lectures that we provide to our fellows. And in conclusion, I just wanted to emphasize that investing in APP Fellowship allows us to maintain a robust pipeline of skilled providers who are aligned with our commitment to excellence in patient care. APP Fellowship has proven to be a feasible strategy for recruitment, training, and retention of APPs. We're training our fourth cohort of EP-APPs currently. To date, we trained and graduated six EP-APP fellows. Five out of six are hired at Stanford. Graduates quickly adapted to clinical practice within our service and are able to interpret EKGs, manage complex arrhythmias, perform cardioversion procedures, and handle CAED management with minimal supervision within the fourth week of their employment. So far, the retention rate for EP-APP fellows stands at 83%. All graduates are active members of our EP team. Former fellows have taken on active roles as clinical preceptors, serving as advisors and alumni for our APP Fellowship program, and are actively involved in providing lectures and participating in simulation lab. Thank you so much for your attention. I will be participating in a roundtable discussion on the same topic, so if you have further questions or want to discuss your organizational programs, love to hear you. Thank you so much. On the app. And just wanna end by saying that this won't be possible without the whole team. Very supporting providers and organizational support. Thank you. Thank you, Angela. There is a question on the app before you leave the mic where you mentioned that your fellows are paid and benefited, but who pays for that? Is it the hospital? The hospital. The hospital does, okay. As a mechanism to? To retain them. Retain future, okay. So we do have more questions, actually more billing-related as expected. One of the questions is, in a hospital-based outpatient clinic, can the patient be listed on the attending schedule? The APP sees the patient first, then MD sees patient on the same day and completes the majority of the MDM and MD attests APP's note and bill. Yeah, so that's the model where I work at the hospital, the University of Pennsylvania. I'll see a patient, then my physician will see the patient. They attest the note. We do also see patients independently. That obviously is kind of cleaner billing-wise, but yeah, that's the model, that we're both seeing the patient on the same day. On that same note, another question came up. How do we, in office work that we have, how do you show your productivity when it's not really billable to that question? Yeah, well, that's the golden goose, right? Like, how do we do that? I mean, obviously, we're all documenting in the EMR, but who's gonna sit there and log? You know, like, I mean, if somebody comes at you and says, like, hey, what have you done all day? You literally have to sort of do that. Sort of do that independently, you know, like, separately. So that, you know, there is really no way. There's people in private practice, like James O'Hara, he might be here, somewhere that have, you know, like, they've figured out, like, there's actually, you can bill for telephone calls and things like that. We're not doing that, but maybe we should be, you know. One thing we added that, I was an underutilizer, but I've learned that it's accepted, whatnot. The new G2211 codes. Yeah, we've been using that, too. You know, that's the whole reason behind them, to know that you're seeing them maybe once every year, but you know you're gonna answer phone calls, refill prescriptions, and whatnot. And so adding that in. Yeah, and so that has been built into our EMR, the, you know, like, literally, and then it comes up as a pop-up, like, you know, administration's figured that one out, too. Like, it comes up as a pop-up. Hey, you know, you should be bill, you know, perhaps you should add this code. So, but it's really not that much money, but every little bit counts. So, I mean, you know. Shows productivity. It does show productivity, so. And you can't build those, apparently, well, like, we've been told, like, on the visit, like, if you're seeing a device patient, and you're going for a visit in the device, you can't bill that code, which is kind of irritating, because again, those people need continuity of care, as well, but. Right, even an EKG will throw it out. But most of us use EMRs, of course, and Epic does have the capability to develop signal data. If you go into the Epic user web signal, I can pull up all my APPs, and I can see how much time, on average, they're spending in inbox, and those kind of things. It's not perfect, it's usually averages, but it helps those conversations. I know our manager, our lead person, not infrequently, he gets, literally, reports that say, this person is spending this much time. So, yeah, if somebody does come at, you know, like. How much pajama time is there going on? Do they need help? So, I mean, there are ways to do it, and it's a computer, so you should be able to do it better. I mean, I just need to learn how to do it better. Again, you sort of, I mean, a lot of that, again, is unbillable, though, like, or, you know, so it's, you know, you're not generating our views. So if somebody's saying, like, from a purely RVU standpoint, like, you're not getting RVUs for that time, if you're an RVU generator. Uh-oh. I guess we have time for one more question. There's somebody in the audience. Oh, oh, sorry. Thank you. Thank you, speakers. My question is about the fellowship program. I'm curious to know how you're planning on using APPs in the lab, yeah, going forward. Yeah, thank you for your question. So there are two lab roles. One is sort of the outside. They do peri-procedural management, and that's been very successful and extremely valuable. The other role is actually assisting in the procedure in the lab. So getting access, closing the pocket, assisting with the procedure throughout the procedure. Like I said, it's still under development. I'd love to hear any suggestions if you guys have. But also, part of the role of lab APP would be independent implant of ILRs, which we're already doing, and Madeline is part of that program. So yeah, we're still developing it, but mainly it's the access, closing, and assisting throughout the procedure. Okay, great. Unfortunately, we do have a bunch more questions here, but we don't have any time to answer them anymore. I apologize for that. A majority of those questions actually are really related to the fellowship program, and as Angela already mentioned before, there's a roundtable going on about, what time was it, 3.30, I think? In the afternoon, right? Yeah. In the afternoon, right? And if you have any questions, Angela will be there, and maybe a few people from Stanford actually will join in and can help answer those questions you are having. Okay, thank you so much for coming, everybody, and I hope you enjoyed the session the same way I did. Thank you.

Advanced Practice Providers

Medicare changes

scope of practice

workforce strategies

split-shared billing

APP-physician collaboration

Stanford APP Fellowship

nurse practitioners

physician associates

healthcare integration