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E-Prescribing is E-Slow
Health information technology, including e-prescribing, is “truly on the national marquee,” according to Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Technology (AHRQ). Speaking at the Annual Conference of the Healthcare Information and Management Systems Society earlier this year, she said, “Americans are quickly coming to understand how much we have to gain from health information technology (HIT). And one thing about Americans—we don’t like to wait.”
Clancy and other government officials have been pushing for widespread implementation and use of e-prescribing and other HIT in hospitals and other care settings. In 2003 the Medicare Modernization Act included a provision offering grants to physicians who implement e-prescribing systems. While all of the talk and action have stopped short of mandating the use of this technology, the handwriting is clearly on the wall. Like it or not, e-prescribing is part of healthcare’s future.
Yet despite all of these efforts on behalf of HIT few physicians are jumping on the e-prescribing bandwagon. Current estimates show that only between 5% and 18% of physicians and other clinicians use e-prescribing.
Nonetheless, while few physicians use these systems, they clearly see their value. In one survey, 78% of physicians say they believe that within the next seven years e-prescribing will account for more than half of the prescriptions written; and 75% cited reduced medication errors and time savings as two benefits of this technology.1 Another survey showed that while only 5% of physicians say they use their handheld computers for prescribing, 100% say that they use their PDAs for drug information.2
Despite the technology’s benefits, there are many reasons hospitalists and other physicians have resisted the call of e-prescribing. However, it behooves these practitioners to know about e-prescribing, consider how they might implement various technologies in their prescribing practices, and become involved in HIT initiatives at their facilities.
Money Matters: Costs Can Keep Hospitalists from E-Prescribing
E-prescribing is not widespread among hospitalists and other physicians, suggests Philip Strong, MD, IT physician liaison at El Camino Hospital and a hospitalist with the El Camino Medical Center in Mountain View, Calif.
Mark Zielzinski, chief information officer at El Camino, says that e-prescribing doesn’t really fit well with what hospitalists do.
E-prescribing is “wonderful in the physician’s office,” he explains. This is because the community-based physician writes many prescriptions every day and needs to communicate prescription information to a wide array of facilities and pharmacies.
“Hospitalists write far fewer prescriptions than attending physicians,” says Ronald Newman, MD, medical director of the hospitalist program at Beverly Hospital in Beverly, Mass. “I don’t write more than five a day.” An e-prescribing system simply isn’t practical for him.
Dr. Strong suggests, however, that the lack of enthusiasm for e-prescribing has more “to do with dollars. Systems are fairly expensive,” he says because a good system could cost as much as $150,000.
Why so much? “For a system to make sense and create more work for hospitalists, it has to interface with whatever system a hospital is using for pharmacies in the area,” explains Dr. Strong. And this can be expensive.
The cost for an individual physician or a small practice to implement e-prescribing seems much more reasonable. However, Dr. Zielzinski says that this represents only about 20% of the total cost of new technology.
“Think of what you spend when you get a home computer,” he says. “Say you spend $1,000 for the PC itself. Then you have to buy software, Internet access, a printer, and other accessories. Then you have to take the time to learn to use it all. Consider everything you spend in five years, and that $1,000 is a drop in the bucket.”
Dr. Zielzinski emphasizes that it’s not just the money that keeps hospitalists and other physicians from using e-prescribing. “Physicians have an intrinsic sociological resistance to change. After all, they are accustomed to evidence-based care and they are expected to have evidence to back up their decisions and actions,” he says, adding that “it takes a new clinical technique, theory, or practice an average of 17 years to get into mainstream practice. So how can we expect to accept new technology just like that?”
—Philip Strong, MD
Practical Protests: When Systems Hinder Efficiency
Another barrier to hospitalist acceptance of e-prescribing and other technology is that it sometimes takes longer to use, especially at the beginning.
“I’m part of an eight-hospitalist team, and we could use an e-prescribing system that our medical group has deployed, but we don’t,” admits Dr. Strong. “To use e-prescribing would require an extra step of work for us. We already have to dictate discharge notes and handwrite prescriptions. We don’t have the ability to substitute e-prescribing; it would just be an additional tool—and an additional step that would slow down our discharges.”
Dr. Newman agrees that physicians won’t use time-consuming technology. “Many systems take a lot of time to learn to use efficiently and effectively,” he says. “Physicians are afraid that these systems, such as e-prescribing, will slow them down and hurt their efficiency.”
He says hospitals are concerned about this and are waiting to implement systems they know physicians will use.
Eric Reines, MD, vice president of North Suburban Hospitalists PC and a hospitalist at Beverly Hospital, confesses to being a techie who enjoys this stuff. He says, however, that “most of the e-prescribing systems I’ve seen have been very poor. I like technology, but I won’t use a clunky system.”
Ease of use is essential for hospitalist acceptance of e-prescribing systems. “You can’t have a system with boxes popping up all over the screen and small black and white type that you can’t read,” says Dr. Reines. “Hospitalists and other physicians just won’t use these.”
Implementing systems that physicians don’t like is a worry that IT developers at hospitals think about about continually, confesses Dr. Zielzinski. “The biggest thing that keeps me awake at night is worrying that physicians will say, ‘This takes too long,’ ” he says, emphasizing that it’s important to educate physicians about how to use systems to make the most of their features and maximize efficiency.
While hospitals are concerned about how physicians will react to the implementation of technology, physicians’ general resistance to using e-prescribing actually could be a boon for hospitalists.
“Attending physicians aren’t likely to leave hospitals because they are required to use e-prescribing or other technology, but they might be more inclined to turn patients over to hospitalists at these facilities so that they don’t have to use these systems,” says Dr. Newman.
Vendor Vexation
Physicians often face the challenge of finding systems and software that integrate successfully with other systems and settings. Dr. Reines says vendors don’t always make widespread system compatibility a priority during product development.
Some data further suggest that e-prescribing products don’t always meet users’ needs. A report commissioned by the California Health Care Foundation evaluated 19 e-prescribing product vendors and found only four offer practical alternatives to more costly and complex prescription writing solutions.
CPOE First … Then E-Prescribing
Before you jump into e-prescribing, Dr. Strong suggests that more hospitals need to implement computerized physician order entry systems (CPOE). CPOE goes beyond prescriptions and enables physicians to electronically order everything from laboratory tests and dietary interventions to nursing care.
CPOE isn’t new; El Camino has used such a system for 30 years. “We are big-time believers in CPOE,” says Dr. Zielzinski. “It has enabled us to reduce a lot of errors.”
Dr. Strong adds that “these systems are better for overall patient through-put. The routing happens as soon as I input the order. There are no faxes, no paperwork, and no delays.”
Other groups also have long promoted the benefits of CPOE. For example, the Leapfrog Group, an organization of large healthcare purchasers, has suggested standards for CPOE systems that can intercept 50% or more of common serious prescribing errors. At the same time, a number of studies have been published documenting the value of CPOE in reducing medication errors and preventable adverse drug events.
Despite the benefits of CPOE, hospitals have been slow to implement it and many physicians oppose its use. “It’s high time we got over that,” says Dr. Strong. “We need to embrace CPOE now. If we do, e-prescribing won’t be such a shock when it comes down the pike.”
When e-prescribing piggybacks a good CPOE system, it will make more sense. “And when e-prescribing is done well, it will make more sense for physicians to embrace it,” he says. “Until then, it doesn’t make sense for most common situations.”
Dr. Zielzinski agrees that physicians and others need to get over their fear of CPOE. “I think you’ll find that CMS, JCAHO, the Leapfrog Group, and others will push more and more for this to happen. It’s the right thing to do.”
When Hospitalists Embrace High Tech
It is important to emphasize that many hospitalists and other physicians embrace technology. “The reality is that physicians come [to El Camino] because of our technology—it’s part of our culture,” says Dr. Zielzinski. When hospitalists join the El Camino staff, they go through a high-tech orientation with a physician trainer.
Pediatric Hospitalist Bettina Ackerman, MD, uses e-prescribing at her facility, Children’s Hospital of Pittsburgh (Pa.), and she likes the system. She admits that certain aspects of the technology can be cumbersome.
For example, “it’s much easier to handwrite certain information, such as complicated dosing instructions that require a lot of text,” she says. Nonetheless, she has seen the benefits as well. “It has drastically reduced medication errors in our hospital. And there is an efficiency that wasn’t there before.”
Dr. Reines stated that hospitalists are like other physicians: Some of them like e-prescribing and other technology, while others don’t. Age isn’t always a predictor, he emphasizes, noting that he is “the oldest physician in his group but I’m also the most interested in technology.” However, he suggested that hospitalists who are “fresh out of training are more used to technology such as e-prescribing. They kind of expect to use it.”
The Hospitalist’s Role … Starting Now
Dr. Strong suggests that hospitalists need to be part of the IT solution. In fact, they already are actively involved in his facility. “It is important for hospitalists to know what HIT their facilities are using and considering for purchase,” he says.
Dr. Reines agrees that physicians need to be active in IT decisions at their hospitals. “I’m on the tech committee at my facility, as are several physicians,” he explains, adding that they have strong opinions and specific input on what they want HIT programs and systems to do, what information they need, and how they expect technology to work to enhance their efficiency and benefit their patients.
Hospitalists who work at teaching hospitals can have a role in educating students about technology. “We need to look at learning opportunities that involve technology,” says Dr. Reines. “And we should encourage people not to be afraid of technology or change.”
Why Bother?
If there are so many barriers to e-prescribing and so many contraindications to its use, why should hospitalists bother with this technology?
While there is much disagreement about the use, benefits, and drawbacks of e-prescribing, there is little doubt that government agencies, regulatory bodies, and third-party payers will continue to push for the widespread implementation of such technology in the coming years.
For example, JCAHO’s establishment of the medication reconciliation process, whereby hospitals and other healthcare providers are expected to compile and use medication lists whenever patients move to a new setting will make e-prescribing more important and practical for hospitalists.
“The need to reconcile our patients’ medications at admission, during their stay, and at discharge will spur a greater need for e-prescribing,” says Dr. Zielzinski.
Dr. Ackerman urges her colleagues to learn about e-prescribing and other systems now. However, she also encourages “the powers that be” to provide more specific guidance on HIT to help physicians and others make the best use of it.
Although he doesn’t use or have a real need for e-prescribing, “I certainly think we will be seeing more hospitalists and hospitals using these systems in the coming years,” says Dr. Newman. “The opportunity—however small—to prevent certain types of errors will make it worthwhile eventually in most settings.” TH
Writer Joanne Kaldy is based in Maryland.
References
- iHealthbeat. Survey: few docs use PDAs for e-prescribing. Sept. 8, 2005. Available at ihealthbeat.org. Last accessed Sept. 14, 2005.
- Mobile Village. Docs embrace handheld e-prescribing to save time, prevent errors. Mobile & Wireless News. Feb. 7, 2003.
Health information technology, including e-prescribing, is “truly on the national marquee,” according to Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Technology (AHRQ). Speaking at the Annual Conference of the Healthcare Information and Management Systems Society earlier this year, she said, “Americans are quickly coming to understand how much we have to gain from health information technology (HIT). And one thing about Americans—we don’t like to wait.”
Clancy and other government officials have been pushing for widespread implementation and use of e-prescribing and other HIT in hospitals and other care settings. In 2003 the Medicare Modernization Act included a provision offering grants to physicians who implement e-prescribing systems. While all of the talk and action have stopped short of mandating the use of this technology, the handwriting is clearly on the wall. Like it or not, e-prescribing is part of healthcare’s future.
Yet despite all of these efforts on behalf of HIT few physicians are jumping on the e-prescribing bandwagon. Current estimates show that only between 5% and 18% of physicians and other clinicians use e-prescribing.
Nonetheless, while few physicians use these systems, they clearly see their value. In one survey, 78% of physicians say they believe that within the next seven years e-prescribing will account for more than half of the prescriptions written; and 75% cited reduced medication errors and time savings as two benefits of this technology.1 Another survey showed that while only 5% of physicians say they use their handheld computers for prescribing, 100% say that they use their PDAs for drug information.2
Despite the technology’s benefits, there are many reasons hospitalists and other physicians have resisted the call of e-prescribing. However, it behooves these practitioners to know about e-prescribing, consider how they might implement various technologies in their prescribing practices, and become involved in HIT initiatives at their facilities.
Money Matters: Costs Can Keep Hospitalists from E-Prescribing
E-prescribing is not widespread among hospitalists and other physicians, suggests Philip Strong, MD, IT physician liaison at El Camino Hospital and a hospitalist with the El Camino Medical Center in Mountain View, Calif.
Mark Zielzinski, chief information officer at El Camino, says that e-prescribing doesn’t really fit well with what hospitalists do.
E-prescribing is “wonderful in the physician’s office,” he explains. This is because the community-based physician writes many prescriptions every day and needs to communicate prescription information to a wide array of facilities and pharmacies.
“Hospitalists write far fewer prescriptions than attending physicians,” says Ronald Newman, MD, medical director of the hospitalist program at Beverly Hospital in Beverly, Mass. “I don’t write more than five a day.” An e-prescribing system simply isn’t practical for him.
Dr. Strong suggests, however, that the lack of enthusiasm for e-prescribing has more “to do with dollars. Systems are fairly expensive,” he says because a good system could cost as much as $150,000.
Why so much? “For a system to make sense and create more work for hospitalists, it has to interface with whatever system a hospital is using for pharmacies in the area,” explains Dr. Strong. And this can be expensive.
The cost for an individual physician or a small practice to implement e-prescribing seems much more reasonable. However, Dr. Zielzinski says that this represents only about 20% of the total cost of new technology.
“Think of what you spend when you get a home computer,” he says. “Say you spend $1,000 for the PC itself. Then you have to buy software, Internet access, a printer, and other accessories. Then you have to take the time to learn to use it all. Consider everything you spend in five years, and that $1,000 is a drop in the bucket.”
Dr. Zielzinski emphasizes that it’s not just the money that keeps hospitalists and other physicians from using e-prescribing. “Physicians have an intrinsic sociological resistance to change. After all, they are accustomed to evidence-based care and they are expected to have evidence to back up their decisions and actions,” he says, adding that “it takes a new clinical technique, theory, or practice an average of 17 years to get into mainstream practice. So how can we expect to accept new technology just like that?”
—Philip Strong, MD
Practical Protests: When Systems Hinder Efficiency
Another barrier to hospitalist acceptance of e-prescribing and other technology is that it sometimes takes longer to use, especially at the beginning.
“I’m part of an eight-hospitalist team, and we could use an e-prescribing system that our medical group has deployed, but we don’t,” admits Dr. Strong. “To use e-prescribing would require an extra step of work for us. We already have to dictate discharge notes and handwrite prescriptions. We don’t have the ability to substitute e-prescribing; it would just be an additional tool—and an additional step that would slow down our discharges.”
Dr. Newman agrees that physicians won’t use time-consuming technology. “Many systems take a lot of time to learn to use efficiently and effectively,” he says. “Physicians are afraid that these systems, such as e-prescribing, will slow them down and hurt their efficiency.”
He says hospitals are concerned about this and are waiting to implement systems they know physicians will use.
Eric Reines, MD, vice president of North Suburban Hospitalists PC and a hospitalist at Beverly Hospital, confesses to being a techie who enjoys this stuff. He says, however, that “most of the e-prescribing systems I’ve seen have been very poor. I like technology, but I won’t use a clunky system.”
Ease of use is essential for hospitalist acceptance of e-prescribing systems. “You can’t have a system with boxes popping up all over the screen and small black and white type that you can’t read,” says Dr. Reines. “Hospitalists and other physicians just won’t use these.”
Implementing systems that physicians don’t like is a worry that IT developers at hospitals think about about continually, confesses Dr. Zielzinski. “The biggest thing that keeps me awake at night is worrying that physicians will say, ‘This takes too long,’ ” he says, emphasizing that it’s important to educate physicians about how to use systems to make the most of their features and maximize efficiency.
While hospitals are concerned about how physicians will react to the implementation of technology, physicians’ general resistance to using e-prescribing actually could be a boon for hospitalists.
“Attending physicians aren’t likely to leave hospitals because they are required to use e-prescribing or other technology, but they might be more inclined to turn patients over to hospitalists at these facilities so that they don’t have to use these systems,” says Dr. Newman.
Vendor Vexation
Physicians often face the challenge of finding systems and software that integrate successfully with other systems and settings. Dr. Reines says vendors don’t always make widespread system compatibility a priority during product development.
Some data further suggest that e-prescribing products don’t always meet users’ needs. A report commissioned by the California Health Care Foundation evaluated 19 e-prescribing product vendors and found only four offer practical alternatives to more costly and complex prescription writing solutions.
CPOE First … Then E-Prescribing
Before you jump into e-prescribing, Dr. Strong suggests that more hospitals need to implement computerized physician order entry systems (CPOE). CPOE goes beyond prescriptions and enables physicians to electronically order everything from laboratory tests and dietary interventions to nursing care.
CPOE isn’t new; El Camino has used such a system for 30 years. “We are big-time believers in CPOE,” says Dr. Zielzinski. “It has enabled us to reduce a lot of errors.”
Dr. Strong adds that “these systems are better for overall patient through-put. The routing happens as soon as I input the order. There are no faxes, no paperwork, and no delays.”
Other groups also have long promoted the benefits of CPOE. For example, the Leapfrog Group, an organization of large healthcare purchasers, has suggested standards for CPOE systems that can intercept 50% or more of common serious prescribing errors. At the same time, a number of studies have been published documenting the value of CPOE in reducing medication errors and preventable adverse drug events.
Despite the benefits of CPOE, hospitals have been slow to implement it and many physicians oppose its use. “It’s high time we got over that,” says Dr. Strong. “We need to embrace CPOE now. If we do, e-prescribing won’t be such a shock when it comes down the pike.”
When e-prescribing piggybacks a good CPOE system, it will make more sense. “And when e-prescribing is done well, it will make more sense for physicians to embrace it,” he says. “Until then, it doesn’t make sense for most common situations.”
Dr. Zielzinski agrees that physicians and others need to get over their fear of CPOE. “I think you’ll find that CMS, JCAHO, the Leapfrog Group, and others will push more and more for this to happen. It’s the right thing to do.”
When Hospitalists Embrace High Tech
It is important to emphasize that many hospitalists and other physicians embrace technology. “The reality is that physicians come [to El Camino] because of our technology—it’s part of our culture,” says Dr. Zielzinski. When hospitalists join the El Camino staff, they go through a high-tech orientation with a physician trainer.
Pediatric Hospitalist Bettina Ackerman, MD, uses e-prescribing at her facility, Children’s Hospital of Pittsburgh (Pa.), and she likes the system. She admits that certain aspects of the technology can be cumbersome.
For example, “it’s much easier to handwrite certain information, such as complicated dosing instructions that require a lot of text,” she says. Nonetheless, she has seen the benefits as well. “It has drastically reduced medication errors in our hospital. And there is an efficiency that wasn’t there before.”
Dr. Reines stated that hospitalists are like other physicians: Some of them like e-prescribing and other technology, while others don’t. Age isn’t always a predictor, he emphasizes, noting that he is “the oldest physician in his group but I’m also the most interested in technology.” However, he suggested that hospitalists who are “fresh out of training are more used to technology such as e-prescribing. They kind of expect to use it.”
The Hospitalist’s Role … Starting Now
Dr. Strong suggests that hospitalists need to be part of the IT solution. In fact, they already are actively involved in his facility. “It is important for hospitalists to know what HIT their facilities are using and considering for purchase,” he says.
Dr. Reines agrees that physicians need to be active in IT decisions at their hospitals. “I’m on the tech committee at my facility, as are several physicians,” he explains, adding that they have strong opinions and specific input on what they want HIT programs and systems to do, what information they need, and how they expect technology to work to enhance their efficiency and benefit their patients.
Hospitalists who work at teaching hospitals can have a role in educating students about technology. “We need to look at learning opportunities that involve technology,” says Dr. Reines. “And we should encourage people not to be afraid of technology or change.”
Why Bother?
If there are so many barriers to e-prescribing and so many contraindications to its use, why should hospitalists bother with this technology?
While there is much disagreement about the use, benefits, and drawbacks of e-prescribing, there is little doubt that government agencies, regulatory bodies, and third-party payers will continue to push for the widespread implementation of such technology in the coming years.
For example, JCAHO’s establishment of the medication reconciliation process, whereby hospitals and other healthcare providers are expected to compile and use medication lists whenever patients move to a new setting will make e-prescribing more important and practical for hospitalists.
“The need to reconcile our patients’ medications at admission, during their stay, and at discharge will spur a greater need for e-prescribing,” says Dr. Zielzinski.
Dr. Ackerman urges her colleagues to learn about e-prescribing and other systems now. However, she also encourages “the powers that be” to provide more specific guidance on HIT to help physicians and others make the best use of it.
Although he doesn’t use or have a real need for e-prescribing, “I certainly think we will be seeing more hospitalists and hospitals using these systems in the coming years,” says Dr. Newman. “The opportunity—however small—to prevent certain types of errors will make it worthwhile eventually in most settings.” TH
Writer Joanne Kaldy is based in Maryland.
References
- iHealthbeat. Survey: few docs use PDAs for e-prescribing. Sept. 8, 2005. Available at ihealthbeat.org. Last accessed Sept. 14, 2005.
- Mobile Village. Docs embrace handheld e-prescribing to save time, prevent errors. Mobile & Wireless News. Feb. 7, 2003.
Health information technology, including e-prescribing, is “truly on the national marquee,” according to Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Technology (AHRQ). Speaking at the Annual Conference of the Healthcare Information and Management Systems Society earlier this year, she said, “Americans are quickly coming to understand how much we have to gain from health information technology (HIT). And one thing about Americans—we don’t like to wait.”
Clancy and other government officials have been pushing for widespread implementation and use of e-prescribing and other HIT in hospitals and other care settings. In 2003 the Medicare Modernization Act included a provision offering grants to physicians who implement e-prescribing systems. While all of the talk and action have stopped short of mandating the use of this technology, the handwriting is clearly on the wall. Like it or not, e-prescribing is part of healthcare’s future.
Yet despite all of these efforts on behalf of HIT few physicians are jumping on the e-prescribing bandwagon. Current estimates show that only between 5% and 18% of physicians and other clinicians use e-prescribing.
Nonetheless, while few physicians use these systems, they clearly see their value. In one survey, 78% of physicians say they believe that within the next seven years e-prescribing will account for more than half of the prescriptions written; and 75% cited reduced medication errors and time savings as two benefits of this technology.1 Another survey showed that while only 5% of physicians say they use their handheld computers for prescribing, 100% say that they use their PDAs for drug information.2
Despite the technology’s benefits, there are many reasons hospitalists and other physicians have resisted the call of e-prescribing. However, it behooves these practitioners to know about e-prescribing, consider how they might implement various technologies in their prescribing practices, and become involved in HIT initiatives at their facilities.
Money Matters: Costs Can Keep Hospitalists from E-Prescribing
E-prescribing is not widespread among hospitalists and other physicians, suggests Philip Strong, MD, IT physician liaison at El Camino Hospital and a hospitalist with the El Camino Medical Center in Mountain View, Calif.
Mark Zielzinski, chief information officer at El Camino, says that e-prescribing doesn’t really fit well with what hospitalists do.
E-prescribing is “wonderful in the physician’s office,” he explains. This is because the community-based physician writes many prescriptions every day and needs to communicate prescription information to a wide array of facilities and pharmacies.
“Hospitalists write far fewer prescriptions than attending physicians,” says Ronald Newman, MD, medical director of the hospitalist program at Beverly Hospital in Beverly, Mass. “I don’t write more than five a day.” An e-prescribing system simply isn’t practical for him.
Dr. Strong suggests, however, that the lack of enthusiasm for e-prescribing has more “to do with dollars. Systems are fairly expensive,” he says because a good system could cost as much as $150,000.
Why so much? “For a system to make sense and create more work for hospitalists, it has to interface with whatever system a hospital is using for pharmacies in the area,” explains Dr. Strong. And this can be expensive.
The cost for an individual physician or a small practice to implement e-prescribing seems much more reasonable. However, Dr. Zielzinski says that this represents only about 20% of the total cost of new technology.
“Think of what you spend when you get a home computer,” he says. “Say you spend $1,000 for the PC itself. Then you have to buy software, Internet access, a printer, and other accessories. Then you have to take the time to learn to use it all. Consider everything you spend in five years, and that $1,000 is a drop in the bucket.”
Dr. Zielzinski emphasizes that it’s not just the money that keeps hospitalists and other physicians from using e-prescribing. “Physicians have an intrinsic sociological resistance to change. After all, they are accustomed to evidence-based care and they are expected to have evidence to back up their decisions and actions,” he says, adding that “it takes a new clinical technique, theory, or practice an average of 17 years to get into mainstream practice. So how can we expect to accept new technology just like that?”
—Philip Strong, MD
Practical Protests: When Systems Hinder Efficiency
Another barrier to hospitalist acceptance of e-prescribing and other technology is that it sometimes takes longer to use, especially at the beginning.
“I’m part of an eight-hospitalist team, and we could use an e-prescribing system that our medical group has deployed, but we don’t,” admits Dr. Strong. “To use e-prescribing would require an extra step of work for us. We already have to dictate discharge notes and handwrite prescriptions. We don’t have the ability to substitute e-prescribing; it would just be an additional tool—and an additional step that would slow down our discharges.”
Dr. Newman agrees that physicians won’t use time-consuming technology. “Many systems take a lot of time to learn to use efficiently and effectively,” he says. “Physicians are afraid that these systems, such as e-prescribing, will slow them down and hurt their efficiency.”
He says hospitals are concerned about this and are waiting to implement systems they know physicians will use.
Eric Reines, MD, vice president of North Suburban Hospitalists PC and a hospitalist at Beverly Hospital, confesses to being a techie who enjoys this stuff. He says, however, that “most of the e-prescribing systems I’ve seen have been very poor. I like technology, but I won’t use a clunky system.”
Ease of use is essential for hospitalist acceptance of e-prescribing systems. “You can’t have a system with boxes popping up all over the screen and small black and white type that you can’t read,” says Dr. Reines. “Hospitalists and other physicians just won’t use these.”
Implementing systems that physicians don’t like is a worry that IT developers at hospitals think about about continually, confesses Dr. Zielzinski. “The biggest thing that keeps me awake at night is worrying that physicians will say, ‘This takes too long,’ ” he says, emphasizing that it’s important to educate physicians about how to use systems to make the most of their features and maximize efficiency.
While hospitals are concerned about how physicians will react to the implementation of technology, physicians’ general resistance to using e-prescribing actually could be a boon for hospitalists.
“Attending physicians aren’t likely to leave hospitals because they are required to use e-prescribing or other technology, but they might be more inclined to turn patients over to hospitalists at these facilities so that they don’t have to use these systems,” says Dr. Newman.
Vendor Vexation
Physicians often face the challenge of finding systems and software that integrate successfully with other systems and settings. Dr. Reines says vendors don’t always make widespread system compatibility a priority during product development.
Some data further suggest that e-prescribing products don’t always meet users’ needs. A report commissioned by the California Health Care Foundation evaluated 19 e-prescribing product vendors and found only four offer practical alternatives to more costly and complex prescription writing solutions.
CPOE First … Then E-Prescribing
Before you jump into e-prescribing, Dr. Strong suggests that more hospitals need to implement computerized physician order entry systems (CPOE). CPOE goes beyond prescriptions and enables physicians to electronically order everything from laboratory tests and dietary interventions to nursing care.
CPOE isn’t new; El Camino has used such a system for 30 years. “We are big-time believers in CPOE,” says Dr. Zielzinski. “It has enabled us to reduce a lot of errors.”
Dr. Strong adds that “these systems are better for overall patient through-put. The routing happens as soon as I input the order. There are no faxes, no paperwork, and no delays.”
Other groups also have long promoted the benefits of CPOE. For example, the Leapfrog Group, an organization of large healthcare purchasers, has suggested standards for CPOE systems that can intercept 50% or more of common serious prescribing errors. At the same time, a number of studies have been published documenting the value of CPOE in reducing medication errors and preventable adverse drug events.
Despite the benefits of CPOE, hospitals have been slow to implement it and many physicians oppose its use. “It’s high time we got over that,” says Dr. Strong. “We need to embrace CPOE now. If we do, e-prescribing won’t be such a shock when it comes down the pike.”
When e-prescribing piggybacks a good CPOE system, it will make more sense. “And when e-prescribing is done well, it will make more sense for physicians to embrace it,” he says. “Until then, it doesn’t make sense for most common situations.”
Dr. Zielzinski agrees that physicians and others need to get over their fear of CPOE. “I think you’ll find that CMS, JCAHO, the Leapfrog Group, and others will push more and more for this to happen. It’s the right thing to do.”
When Hospitalists Embrace High Tech
It is important to emphasize that many hospitalists and other physicians embrace technology. “The reality is that physicians come [to El Camino] because of our technology—it’s part of our culture,” says Dr. Zielzinski. When hospitalists join the El Camino staff, they go through a high-tech orientation with a physician trainer.
Pediatric Hospitalist Bettina Ackerman, MD, uses e-prescribing at her facility, Children’s Hospital of Pittsburgh (Pa.), and she likes the system. She admits that certain aspects of the technology can be cumbersome.
For example, “it’s much easier to handwrite certain information, such as complicated dosing instructions that require a lot of text,” she says. Nonetheless, she has seen the benefits as well. “It has drastically reduced medication errors in our hospital. And there is an efficiency that wasn’t there before.”
Dr. Reines stated that hospitalists are like other physicians: Some of them like e-prescribing and other technology, while others don’t. Age isn’t always a predictor, he emphasizes, noting that he is “the oldest physician in his group but I’m also the most interested in technology.” However, he suggested that hospitalists who are “fresh out of training are more used to technology such as e-prescribing. They kind of expect to use it.”
The Hospitalist’s Role … Starting Now
Dr. Strong suggests that hospitalists need to be part of the IT solution. In fact, they already are actively involved in his facility. “It is important for hospitalists to know what HIT their facilities are using and considering for purchase,” he says.
Dr. Reines agrees that physicians need to be active in IT decisions at their hospitals. “I’m on the tech committee at my facility, as are several physicians,” he explains, adding that they have strong opinions and specific input on what they want HIT programs and systems to do, what information they need, and how they expect technology to work to enhance their efficiency and benefit their patients.
Hospitalists who work at teaching hospitals can have a role in educating students about technology. “We need to look at learning opportunities that involve technology,” says Dr. Reines. “And we should encourage people not to be afraid of technology or change.”
Why Bother?
If there are so many barriers to e-prescribing and so many contraindications to its use, why should hospitalists bother with this technology?
While there is much disagreement about the use, benefits, and drawbacks of e-prescribing, there is little doubt that government agencies, regulatory bodies, and third-party payers will continue to push for the widespread implementation of such technology in the coming years.
For example, JCAHO’s establishment of the medication reconciliation process, whereby hospitals and other healthcare providers are expected to compile and use medication lists whenever patients move to a new setting will make e-prescribing more important and practical for hospitalists.
“The need to reconcile our patients’ medications at admission, during their stay, and at discharge will spur a greater need for e-prescribing,” says Dr. Zielzinski.
Dr. Ackerman urges her colleagues to learn about e-prescribing and other systems now. However, she also encourages “the powers that be” to provide more specific guidance on HIT to help physicians and others make the best use of it.
Although he doesn’t use or have a real need for e-prescribing, “I certainly think we will be seeing more hospitalists and hospitals using these systems in the coming years,” says Dr. Newman. “The opportunity—however small—to prevent certain types of errors will make it worthwhile eventually in most settings.” TH
Writer Joanne Kaldy is based in Maryland.
References
- iHealthbeat. Survey: few docs use PDAs for e-prescribing. Sept. 8, 2005. Available at ihealthbeat.org. Last accessed Sept. 14, 2005.
- Mobile Village. Docs embrace handheld e-prescribing to save time, prevent errors. Mobile & Wireless News. Feb. 7, 2003.
TRENDWATCH: The Specialization of Hospital Medicine
Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.
According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”
HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS
Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.
The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.
Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.
“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.
“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”
Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”
There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.
This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.
As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.
Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.
Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”
PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES
Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.
“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”
Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”
As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.
KIDS TAKE CENTER STAGE
Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.
“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”
Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.
“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”
Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”
HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?
The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”
Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”
Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.
“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.
PASSING FAD OR GROWING TREND?
Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.
“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”
Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”
With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.
Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.
“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”
RESEARCH SAYS …
Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1
Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.
According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.
“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH
Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.
REFERENCE
- Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.
Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.
According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”
HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS
Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.
The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.
Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.
“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.
“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”
Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”
There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.
This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.
As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.
Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.
Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”
PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES
Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.
“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”
Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”
As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.
KIDS TAKE CENTER STAGE
Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.
“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”
Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.
“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”
Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”
HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?
The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”
Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”
Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.
“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.
PASSING FAD OR GROWING TREND?
Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.
“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”
Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”
With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.
Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.
“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”
RESEARCH SAYS …
Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1
Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.
According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.
“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH
Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.
REFERENCE
- Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.
Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.
According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”
HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS
Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.
The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.
Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.
“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.
“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”
Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”
There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.
This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.
As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.
Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.
Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”
PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES
Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.
“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”
Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”
As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.
KIDS TAKE CENTER STAGE
Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.
“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”
Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.
“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”
Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”
HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?
The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”
Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”
Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.
“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.
PASSING FAD OR GROWING TREND?
Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.
“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”
Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”
With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.
Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.
“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”
RESEARCH SAYS …
Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1
Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.
According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.
“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH
Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.
REFERENCE
- Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.
The Pull is Strong
Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?
Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.
The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.
“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”
Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.
“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”
WHAT IS MAGNET?
Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.
The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:
- Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
- Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
- Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1
—Allen Kaiser, MD
A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.
Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.
Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:
- Consistently outperform nonmagnet organizations;
- Deliver better patient outcomes;
- Have shorter lengths of patient stays;
- Enjoy increased nurse retention rates;
- Report higher rates of nursing job satisfaction; and
- Report higher patient satisfaction.5
To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt
University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.
HOSPITALISTS AND MAGNET
An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.
“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”
Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”
Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.
“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”
Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.
“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”
—Richard Abrams, MD
PERFECT TOGETHER
Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.
“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”
When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.
“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”
Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”
Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”
At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.
While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.
THE WORD SPREADS
If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.
“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”
Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.
“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”
In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”
At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.
“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH
Contributor Joanne Kaldy is based in Maryland.
REFERENCES
- McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
- Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
- American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.
Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?
Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.
The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.
“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”
Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.
“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”
WHAT IS MAGNET?
Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.
The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:
- Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
- Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
- Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1
—Allen Kaiser, MD
A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.
Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.
Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:
- Consistently outperform nonmagnet organizations;
- Deliver better patient outcomes;
- Have shorter lengths of patient stays;
- Enjoy increased nurse retention rates;
- Report higher rates of nursing job satisfaction; and
- Report higher patient satisfaction.5
To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt
University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.
HOSPITALISTS AND MAGNET
An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.
“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”
Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”
Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.
“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”
Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.
“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”
—Richard Abrams, MD
PERFECT TOGETHER
Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.
“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”
When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.
“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”
Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”
Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”
At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.
While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.
THE WORD SPREADS
If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.
“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”
Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.
“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”
In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”
At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.
“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH
Contributor Joanne Kaldy is based in Maryland.
REFERENCES
- McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
- Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
- American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.
Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?
Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.
The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.
“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”
Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.
“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”
WHAT IS MAGNET?
Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.
The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:
- Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
- Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
- Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1
—Allen Kaiser, MD
A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.
Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.
Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:
- Consistently outperform nonmagnet organizations;
- Deliver better patient outcomes;
- Have shorter lengths of patient stays;
- Enjoy increased nurse retention rates;
- Report higher rates of nursing job satisfaction; and
- Report higher patient satisfaction.5
To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt
University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.
HOSPITALISTS AND MAGNET
An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.
“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”
Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”
Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.
“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”
Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.
“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”
—Richard Abrams, MD
PERFECT TOGETHER
Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.
“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”
When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.
“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”
Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”
Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”
At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.
While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.
THE WORD SPREADS
If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.
“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”
Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.
“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”
In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”
At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.
“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH
Contributor Joanne Kaldy is based in Maryland.
REFERENCES
- McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
- Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
- Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
- American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.