MHM

BACKGROUND: Identifying hospitals that are both early and consistent adopters of high-value care can help shed light on the culture and practices at those institutions that are necessary to promote high-value care nationwide. The use of troponin testing to diagnose acute myocardial infarction (AMI), and not testing for myoglobin or creatine kinase-MB (CK-MB), is a high-value recommendation of the Choosing Wisely® campaign.

OBJECTIVE: To examine the variation in cardiac biomarker testing and the effect of the Choosing Wisely® troponin-only testing recommendation for the diagnosis of AMI.

DESIGN: A retrospective, observational study using administrative ordering data from Vizient’s Clinical Database/Resource Manager.

PATIENTS: Hospitalized patients with a principal discharge diagnosis of AMI.

INTERVENTION: The Choosing Wisely® recommendation to order troponin-only testing to diagnose AMI was released during the first quarter of 2015.

RESULTS: In 19 hospitals, troponin-only testing was consistently ordered to diagnose AMI before the Choosing Wisely® recommendation and throughout the study period. In 34 hospitals, both troponin testing and myoglobin/CK-MB testing were ordered to diagnose AMI even after the Choosing Wisely® recommendation. In 26 hospitals with low rates of troponin-only testing before the Choosing Wisely® recommendation, the release of the recommendation was associated with a statistically significant increase in the rate of troponin-only testing to diagnose AMI.

CONCLUSION: In institutions with low rates of troponin-only testing prior to the Choosing Wisely® recommendation, the recommendation was associated with a significant increase in the rate of troponin-only testing.

Read the entire article in the Dec. 2017 issue of the Journal of Hospital Medicine.

Also in JHM this month

Hospital perceptions of Medicare’s Sepsis Quality Reporting Initiative

AUTHORS: Ian J. Barbash, MD, MS; Kimberly J. Rak, PhD; Courtney C. Kuza, MPH; and Jeremy M. Kahn, MD, MS

Health literacy and hospital length of stay: An inpatient cohort study

AUTHORS: Ethan G. Jaffee, MD; Vineet M. Arora, MD, MAPP; Madeleine I. Matthiesen, MD; David O. Meltzer, MD, PhD, MHM; and Valerie G. Press, MD, FAAP, FACP, MPH

How exemplary teaching physicians interact with hospitalized patients

AUTHORS: Sanjay Saint, MD, MPH, FHM; Molly Harrod, PhD; Karen E. Fowler, MPH; and Nathan Houchens, MD, FACP, FHM

A randomized cohort controlled trial to compare intern sign-out training interventions

AUTHORS: Soo-Hoon Lee, PhD; Christopher Terndrup, MD; Phillip H. Phan, PhD; Sandra E. Zaeh, MD; Kwame Atsina, MD; Nicole Minkove, MD; Alexander Billioux, MD; DPhil, Souvik Chatterjee, MD; Idoreyin Montague, MD; Bennett Clark, MD; Andrew Hughes, MD; and Sanjay V. Desai, MD

BACKGROUND: Identifying hospitals that are both early and consistent adopters of high-value care can help shed light on the culture and practices at those institutions that are necessary to promote high-value care nationwide. The use of troponin testing to diagnose acute myocardial infarction (AMI), and not testing for myoglobin or creatine kinase-MB (CK-MB), is a high-value recommendation of the Choosing Wisely® campaign.

OBJECTIVE: To examine the variation in cardiac biomarker testing and the effect of the Choosing Wisely® troponin-only testing recommendation for the diagnosis of AMI.

DESIGN: A retrospective, observational study using administrative ordering data from Vizient’s Clinical Database/Resource Manager.

PATIENTS: Hospitalized patients with a principal discharge diagnosis of AMI.

INTERVENTION: The Choosing Wisely® recommendation to order troponin-only testing to diagnose AMI was released during the first quarter of 2015.

RESULTS: In 19 hospitals, troponin-only testing was consistently ordered to diagnose AMI before the Choosing Wisely® recommendation and throughout the study period. In 34 hospitals, both troponin testing and myoglobin/CK-MB testing were ordered to diagnose AMI even after the Choosing Wisely® recommendation. In 26 hospitals with low rates of troponin-only testing before the Choosing Wisely® recommendation, the release of the recommendation was associated with a statistically significant increase in the rate of troponin-only testing to diagnose AMI.

CONCLUSION: In institutions with low rates of troponin-only testing prior to the Choosing Wisely® recommendation, the recommendation was associated with a significant increase in the rate of troponin-only testing.

Read the entire article in the Dec. 2017 issue of the Journal of Hospital Medicine.

Also in JHM this month

Hospital perceptions of Medicare’s Sepsis Quality Reporting Initiative

AUTHORS: Ian J. Barbash, MD, MS; Kimberly J. Rak, PhD; Courtney C. Kuza, MPH; and Jeremy M. Kahn, MD, MS

Health literacy and hospital length of stay: An inpatient cohort study

AUTHORS: Ethan G. Jaffee, MD; Vineet M. Arora, MD, MAPP; Madeleine I. Matthiesen, MD; David O. Meltzer, MD, PhD, MHM; and Valerie G. Press, MD, FAAP, FACP, MPH

How exemplary teaching physicians interact with hospitalized patients

AUTHORS: Sanjay Saint, MD, MPH, FHM; Molly Harrod, PhD; Karen E. Fowler, MPH; and Nathan Houchens, MD, FACP, FHM

A randomized cohort controlled trial to compare intern sign-out training interventions

AUTHORS: Soo-Hoon Lee, PhD; Christopher Terndrup, MD; Phillip H. Phan, PhD; Sandra E. Zaeh, MD; Kwame Atsina, MD; Nicole Minkove, MD; Alexander Billioux, MD; DPhil, Souvik Chatterjee, MD; Idoreyin Montague, MD; Bennett Clark, MD; Andrew Hughes, MD; and Sanjay V. Desai, MD

BACKGROUND: Identifying hospitals that are both early and consistent adopters of high-value care can help shed light on the culture and practices at those institutions that are necessary to promote high-value care nationwide. The use of troponin testing to diagnose acute myocardial infarction (AMI), and not testing for myoglobin or creatine kinase-MB (CK-MB), is a high-value recommendation of the Choosing Wisely® campaign.

OBJECTIVE: To examine the variation in cardiac biomarker testing and the effect of the Choosing Wisely® troponin-only testing recommendation for the diagnosis of AMI.

DESIGN: A retrospective, observational study using administrative ordering data from Vizient’s Clinical Database/Resource Manager.

PATIENTS: Hospitalized patients with a principal discharge diagnosis of AMI.

INTERVENTION: The Choosing Wisely® recommendation to order troponin-only testing to diagnose AMI was released during the first quarter of 2015.

RESULTS: In 19 hospitals, troponin-only testing was consistently ordered to diagnose AMI before the Choosing Wisely® recommendation and throughout the study period. In 34 hospitals, both troponin testing and myoglobin/CK-MB testing were ordered to diagnose AMI even after the Choosing Wisely® recommendation. In 26 hospitals with low rates of troponin-only testing before the Choosing Wisely® recommendation, the release of the recommendation was associated with a statistically significant increase in the rate of troponin-only testing to diagnose AMI.

CONCLUSION: In institutions with low rates of troponin-only testing prior to the Choosing Wisely® recommendation, the recommendation was associated with a significant increase in the rate of troponin-only testing.

Read the entire article in the Dec. 2017 issue of the Journal of Hospital Medicine.

Also in JHM this month

Hospital perceptions of Medicare’s Sepsis Quality Reporting Initiative

AUTHORS: Ian J. Barbash, MD, MS; Kimberly J. Rak, PhD; Courtney C. Kuza, MPH; and Jeremy M. Kahn, MD, MS

Health literacy and hospital length of stay: An inpatient cohort study

AUTHORS: Ethan G. Jaffee, MD; Vineet M. Arora, MD, MAPP; Madeleine I. Matthiesen, MD; David O. Meltzer, MD, PhD, MHM; and Valerie G. Press, MD, FAAP, FACP, MPH

How exemplary teaching physicians interact with hospitalized patients

AUTHORS: Sanjay Saint, MD, MPH, FHM; Molly Harrod, PhD; Karen E. Fowler, MPH; and Nathan Houchens, MD, FACP, FHM

A randomized cohort controlled trial to compare intern sign-out training interventions

AUTHORS: Soo-Hoon Lee, PhD; Christopher Terndrup, MD; Phillip H. Phan, PhD; Sandra E. Zaeh, MD; Kwame Atsina, MD; Nicole Minkove, MD; Alexander Billioux, MD; DPhil, Souvik Chatterjee, MD; Idoreyin Montague, MD; Bennett Clark, MD; Andrew Hughes, MD; and Sanjay V. Desai, MD

You Have Lowered Length of Stay. Congratulations: You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. Diagnosis Related Group (DRG)–based and capitated payments expedited that shift.

Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and, as best as possible, use what measures they could as a proxy for quality (readmissions and hospital-acquired conditions). Providers balanced the harms of a continued stay with the benefits of added days, not to mention the need for cost savings.

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader …

• Why 7 On/7 Off Doesn’t Meet the Needs of Long-Stay Hospital Patients by Lauren Doctoroff, MD, FHM
• Is It Time for Health Policy M&Ms? by Chris Moriates, MD
• George Carlin Predicts Hospital Planning Strategy by Jordan Messler, MD, SFHM
• Many Paths to a Richer Job by Leslie Flores, MHA, MPH, SFHM
• A New Face for Online Modules by Chris Moriates, MD

You Have Lowered Length of Stay. Congratulations: You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. Diagnosis Related Group (DRG)–based and capitated payments expedited that shift.

Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and, as best as possible, use what measures they could as a proxy for quality (readmissions and hospital-acquired conditions). Providers balanced the harms of a continued stay with the benefits of added days, not to mention the need for cost savings.

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader …

• Why 7 On/7 Off Doesn’t Meet the Needs of Long-Stay Hospital Patients by Lauren Doctoroff, MD, FHM
• Is It Time for Health Policy M&Ms? by Chris Moriates, MD
• George Carlin Predicts Hospital Planning Strategy by Jordan Messler, MD, SFHM
• Many Paths to a Richer Job by Leslie Flores, MHA, MPH, SFHM
• A New Face for Online Modules by Chris Moriates, MD

You Have Lowered Length of Stay. Congratulations: You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. Diagnosis Related Group (DRG)–based and capitated payments expedited that shift.

Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and, as best as possible, use what measures they could as a proxy for quality (readmissions and hospital-acquired conditions). Providers balanced the harms of a continued stay with the benefits of added days, not to mention the need for cost savings.

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader …

• Why 7 On/7 Off Doesn’t Meet the Needs of Long-Stay Hospital Patients by Lauren Doctoroff, MD, FHM
• Is It Time for Health Policy M&Ms? by Chris Moriates, MD
• George Carlin Predicts Hospital Planning Strategy by Jordan Messler, MD, SFHM
• Many Paths to a Richer Job by Leslie Flores, MHA, MPH, SFHM
• A New Face for Online Modules by Chris Moriates, MD

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.

Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.

For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.

Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.

2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.

3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.

Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).

Alicia Ault/Frontline Medical News

Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).

Alicia Ault/Frontline Medical News

Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).

Alicia Ault/Frontline Medical News

Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

Given the amount of time physicians spend entering data, clicking through screens, navigating pages, and logging in to computers, one would have hoped that substantial near-term payback for such efforts would have materialized.

Many of us believed this would take the form of health information exchange – the ability to easily access clinical information from hospitals or clinics other than our own, creating a more complete picture of the patient before us. To our disappointment, true information exchange has yet to materialize. (We won’t debate here whether politics or technology is culpable.) We are left to look elsewhere for the benefits of the digitization of the medical records and other sources of health care knowledge.

Lately, there has been a lot of talk about the promise of machine learning and artificial intelligence (AI) in health care. Much of the resurgence of interest in AI can be traced to IBM Watson’s appearance as a contestant on Jeopardy in 2011. Watson, a natural language supercomputer with enough power to process the equivalent of a million books per second, had access to 200 million pages of content, including the full text of Wikipedia, for Jeopardy.¹ Watson handily outperformed its human opponents – two Jeopardy savants who were also the most successful contestants in game show history – taking the $1 million first prize but struggling in categories with clues containing only a few words.
 

MD Anderson and Watson: Dashed hopes follow initial promise

As a result of growing recognition of AI’s potential in health care, IBM began collaborations with a number of health care organizations to deploy Watson.

In 2013, MD Anderson Cancer Center and IBM began a pilot to develop an oncology clinical decision support technology tool powered by Watson to aid MD Anderson “in its mission to eradicate cancer.” Recently, it was announced that the project – which cost the cancer center $62 million – has been put on hold, and MD Anderson is looking for other contractors to replace IBM.

While administrative problems are at least partly responsible for the project’s challenges, the undertaking has raised issues with the quality and quantity of data in health care that call into question the ability of AI to work as well in health care as it did on Jeopardy, at least in the short term.
 

Health care: Not as data rich as you might think

“We are not ‘Big Data’ in health care, yet.” – Dale Sanders, Health Catalyst.²

In its quest for Jeopardy victory, Watson accessed a massive data storehouse subsuming a vast array of knowledge assembled over the course of human history. Conversely, for health care, Watson is limited to a few decades of scientific journals (that may not contribute to diagnosis and treatment as much as one might think), claims data geared to billing without much clinical information like outcomes, and clinical data from progress notes (plagued by inaccuracies, serial “copy and paste,” and nonstandardized language and numeric representations), and variable-format reports from lab, radiology, pathology, and other disciplines.

To articulate how data-poor health care is, Dale Sanders, executive vice president for software at Health Catalyst, notes that a Boeing 787 generates 500GB of data in a six hour flight while one patient may generate just 100MB of data in an entire year.² He pointed out that, in the near term, AI platforms like Watson simply do not have enough data substrate to impact health care as many hoped it would. Over the longer term, he says, if health care can develop a coherent, standard approach to data content, AI may fulfill its promise.

SKapi/Thinkstock

What can AI and related technologies achieve in the near-term?

“AI seems to have replaced Uber as the most overused word or phrase in digital health.” – Reporter Stephanie Baum, paraphrasing from an interview with Bob Kocher, Venrock Partners.³

My observations tell me that we have already made some progress and are likely to make more strides in the coming years, thanks to AI, machine learning, and natural language processing. A few areas of potential gain are:

Clinical documentation

Technology that can derive meaning from words or groups of words can help with more accurate clinical documentation. For example, if a patient has a documented UTI but also has in the record an 11 on the Glasgow Coma Scale, a systolic BP of 90, and a respiratory rate of 24, technology can alert the physician to document sepsis.

Quality measurement and reporting

Similarly, if technology can recognize words and numbers, it may be able to extract and report quality measures (for example, an ejection fraction of 35% in a heart failure patient) from progress notes without having a nurse-abstractor manually enter such data into structured fields for reporting, as is currently the case.

Predicting readmissions, mortality, other events

While machine learning has had mixed results in predicting future clinical events, this is likely to change as data integrity and algorithms improve. Best-of-breed technology will probably use both clinical and machine learning tools for predictive purposes in the future.

In 2015, I had the privilege of meeting Vinod Khosla, cofounder of SUN Microsystems and venture capitalist, who predicts that computers will largely supplant physicians in the future, at least in domains relying on access to data. As he puts it, “the core functions necessary for complex diagnoses, treatments, and monitoring will be driven by machine judgment instead of human judgment.”⁴

While the benefits of technology, especially in health care, are often oversold, I believe AI and related technologies will some day play a large role alongside physicians in the care of patients. However, for AI to deliver, we must first figure out how to collect and organize health care data so that computers are able to ingest, digest and use it in a purposeful way.

Note: Dr. Whitcomb is founder and advisor to Zato Health, which uses natural language processing and discovery technology in health care.

He is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Zimmer, Ben. Is It Time to Welcome Our New Computer Overlords?. The Atlantic. https://www.theatlantic.com/technology/archive/2011/02/is-it-time-to-welcome-our-new-computer-overlords/71388/. Accessed 23 Apr 2017.

2. Sanders, Dale. The MD Anderson / IBM Watson Announcement: What does it mean for machine learning in healthcare? Webinar. https://www.slideshare.net/healthcatalyst1/the-md-anderson-ibm-watson-announcement-what-does-it-mean-for-machine-learning-in-healthcare. Accessed 23 Apr 2017.

3. Baum, Stephanie. Venrock survey predicts a flight to quality for digital health investments. MedCity News. 12 Apr 2017. http://medcitynews.com/2017/04/venrock-survey-predicts-flight-quality-digital-health-investment/. Accessed 22 Apr 2017.

4. Khosla, Vinod. The Reinvention Of Medicine: Dr. Algorithm V0-7 And Beyond. TechCrunch. 22 Sept 2014. https://techcrunch.com/2014/09/22/the-reinvention-of-medicine-dr-algorithm-version-0-7-and-beyond/. Accessed 22 Apr 2017.

Given the amount of time physicians spend entering data, clicking through screens, navigating pages, and logging in to computers, one would have hoped that substantial near-term payback for such efforts would have materialized.

Many of us believed this would take the form of health information exchange – the ability to easily access clinical information from hospitals or clinics other than our own, creating a more complete picture of the patient before us. To our disappointment, true information exchange has yet to materialize. (We won’t debate here whether politics or technology is culpable.) We are left to look elsewhere for the benefits of the digitization of the medical records and other sources of health care knowledge.

Lately, there has been a lot of talk about the promise of machine learning and artificial intelligence (AI) in health care. Much of the resurgence of interest in AI can be traced to IBM Watson’s appearance as a contestant on Jeopardy in 2011. Watson, a natural language supercomputer with enough power to process the equivalent of a million books per second, had access to 200 million pages of content, including the full text of Wikipedia, for Jeopardy.¹ Watson handily outperformed its human opponents – two Jeopardy savants who were also the most successful contestants in game show history – taking the $1 million first prize but struggling in categories with clues containing only a few words.
 

MD Anderson and Watson: Dashed hopes follow initial promise

As a result of growing recognition of AI’s potential in health care, IBM began collaborations with a number of health care organizations to deploy Watson.

In 2013, MD Anderson Cancer Center and IBM began a pilot to develop an oncology clinical decision support technology tool powered by Watson to aid MD Anderson “in its mission to eradicate cancer.” Recently, it was announced that the project – which cost the cancer center $62 million – has been put on hold, and MD Anderson is looking for other contractors to replace IBM.

While administrative problems are at least partly responsible for the project’s challenges, the undertaking has raised issues with the quality and quantity of data in health care that call into question the ability of AI to work as well in health care as it did on Jeopardy, at least in the short term.
 

Health care: Not as data rich as you might think

“We are not ‘Big Data’ in health care, yet.” – Dale Sanders, Health Catalyst.²

In its quest for Jeopardy victory, Watson accessed a massive data storehouse subsuming a vast array of knowledge assembled over the course of human history. Conversely, for health care, Watson is limited to a few decades of scientific journals (that may not contribute to diagnosis and treatment as much as one might think), claims data geared to billing without much clinical information like outcomes, and clinical data from progress notes (plagued by inaccuracies, serial “copy and paste,” and nonstandardized language and numeric representations), and variable-format reports from lab, radiology, pathology, and other disciplines.

To articulate how data-poor health care is, Dale Sanders, executive vice president for software at Health Catalyst, notes that a Boeing 787 generates 500GB of data in a six hour flight while one patient may generate just 100MB of data in an entire year.² He pointed out that, in the near term, AI platforms like Watson simply do not have enough data substrate to impact health care as many hoped it would. Over the longer term, he says, if health care can develop a coherent, standard approach to data content, AI may fulfill its promise.

SKapi/Thinkstock

What can AI and related technologies achieve in the near-term?

“AI seems to have replaced Uber as the most overused word or phrase in digital health.” – Reporter Stephanie Baum, paraphrasing from an interview with Bob Kocher, Venrock Partners.³

My observations tell me that we have already made some progress and are likely to make more strides in the coming years, thanks to AI, machine learning, and natural language processing. A few areas of potential gain are:

Clinical documentation

Technology that can derive meaning from words or groups of words can help with more accurate clinical documentation. For example, if a patient has a documented UTI but also has in the record an 11 on the Glasgow Coma Scale, a systolic BP of 90, and a respiratory rate of 24, technology can alert the physician to document sepsis.

Quality measurement and reporting

Similarly, if technology can recognize words and numbers, it may be able to extract and report quality measures (for example, an ejection fraction of 35% in a heart failure patient) from progress notes without having a nurse-abstractor manually enter such data into structured fields for reporting, as is currently the case.

Predicting readmissions, mortality, other events

While machine learning has had mixed results in predicting future clinical events, this is likely to change as data integrity and algorithms improve. Best-of-breed technology will probably use both clinical and machine learning tools for predictive purposes in the future.

In 2015, I had the privilege of meeting Vinod Khosla, cofounder of SUN Microsystems and venture capitalist, who predicts that computers will largely supplant physicians in the future, at least in domains relying on access to data. As he puts it, “the core functions necessary for complex diagnoses, treatments, and monitoring will be driven by machine judgment instead of human judgment.”⁴

While the benefits of technology, especially in health care, are often oversold, I believe AI and related technologies will some day play a large role alongside physicians in the care of patients. However, for AI to deliver, we must first figure out how to collect and organize health care data so that computers are able to ingest, digest and use it in a purposeful way.

Note: Dr. Whitcomb is founder and advisor to Zato Health, which uses natural language processing and discovery technology in health care.

He is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Zimmer, Ben. Is It Time to Welcome Our New Computer Overlords?. The Atlantic. https://www.theatlantic.com/technology/archive/2011/02/is-it-time-to-welcome-our-new-computer-overlords/71388/. Accessed 23 Apr 2017.

2. Sanders, Dale. The MD Anderson / IBM Watson Announcement: What does it mean for machine learning in healthcare? Webinar. https://www.slideshare.net/healthcatalyst1/the-md-anderson-ibm-watson-announcement-what-does-it-mean-for-machine-learning-in-healthcare. Accessed 23 Apr 2017.

3. Baum, Stephanie. Venrock survey predicts a flight to quality for digital health investments. MedCity News. 12 Apr 2017. http://medcitynews.com/2017/04/venrock-survey-predicts-flight-quality-digital-health-investment/. Accessed 22 Apr 2017.

4. Khosla, Vinod. The Reinvention Of Medicine: Dr. Algorithm V0-7 And Beyond. TechCrunch. 22 Sept 2014. https://techcrunch.com/2014/09/22/the-reinvention-of-medicine-dr-algorithm-version-0-7-and-beyond/. Accessed 22 Apr 2017.

Given the amount of time physicians spend entering data, clicking through screens, navigating pages, and logging in to computers, one would have hoped that substantial near-term payback for such efforts would have materialized.

Many of us believed this would take the form of health information exchange – the ability to easily access clinical information from hospitals or clinics other than our own, creating a more complete picture of the patient before us. To our disappointment, true information exchange has yet to materialize. (We won’t debate here whether politics or technology is culpable.) We are left to look elsewhere for the benefits of the digitization of the medical records and other sources of health care knowledge.

Lately, there has been a lot of talk about the promise of machine learning and artificial intelligence (AI) in health care. Much of the resurgence of interest in AI can be traced to IBM Watson’s appearance as a contestant on Jeopardy in 2011. Watson, a natural language supercomputer with enough power to process the equivalent of a million books per second, had access to 200 million pages of content, including the full text of Wikipedia, for Jeopardy.¹ Watson handily outperformed its human opponents – two Jeopardy savants who were also the most successful contestants in game show history – taking the $1 million first prize but struggling in categories with clues containing only a few words.
 

MD Anderson and Watson: Dashed hopes follow initial promise

As a result of growing recognition of AI’s potential in health care, IBM began collaborations with a number of health care organizations to deploy Watson.

In 2013, MD Anderson Cancer Center and IBM began a pilot to develop an oncology clinical decision support technology tool powered by Watson to aid MD Anderson “in its mission to eradicate cancer.” Recently, it was announced that the project – which cost the cancer center $62 million – has been put on hold, and MD Anderson is looking for other contractors to replace IBM.

While administrative problems are at least partly responsible for the project’s challenges, the undertaking has raised issues with the quality and quantity of data in health care that call into question the ability of AI to work as well in health care as it did on Jeopardy, at least in the short term.
 

Health care: Not as data rich as you might think

“We are not ‘Big Data’ in health care, yet.” – Dale Sanders, Health Catalyst.²

In its quest for Jeopardy victory, Watson accessed a massive data storehouse subsuming a vast array of knowledge assembled over the course of human history. Conversely, for health care, Watson is limited to a few decades of scientific journals (that may not contribute to diagnosis and treatment as much as one might think), claims data geared to billing without much clinical information like outcomes, and clinical data from progress notes (plagued by inaccuracies, serial “copy and paste,” and nonstandardized language and numeric representations), and variable-format reports from lab, radiology, pathology, and other disciplines.

To articulate how data-poor health care is, Dale Sanders, executive vice president for software at Health Catalyst, notes that a Boeing 787 generates 500GB of data in a six hour flight while one patient may generate just 100MB of data in an entire year.² He pointed out that, in the near term, AI platforms like Watson simply do not have enough data substrate to impact health care as many hoped it would. Over the longer term, he says, if health care can develop a coherent, standard approach to data content, AI may fulfill its promise.

SKapi/Thinkstock

What can AI and related technologies achieve in the near-term?

“AI seems to have replaced Uber as the most overused word or phrase in digital health.” – Reporter Stephanie Baum, paraphrasing from an interview with Bob Kocher, Venrock Partners.³

My observations tell me that we have already made some progress and are likely to make more strides in the coming years, thanks to AI, machine learning, and natural language processing. A few areas of potential gain are:

Clinical documentation

Technology that can derive meaning from words or groups of words can help with more accurate clinical documentation. For example, if a patient has a documented UTI but also has in the record an 11 on the Glasgow Coma Scale, a systolic BP of 90, and a respiratory rate of 24, technology can alert the physician to document sepsis.

Quality measurement and reporting

Similarly, if technology can recognize words and numbers, it may be able to extract and report quality measures (for example, an ejection fraction of 35% in a heart failure patient) from progress notes without having a nurse-abstractor manually enter such data into structured fields for reporting, as is currently the case.

Predicting readmissions, mortality, other events

While machine learning has had mixed results in predicting future clinical events, this is likely to change as data integrity and algorithms improve. Best-of-breed technology will probably use both clinical and machine learning tools for predictive purposes in the future.

In 2015, I had the privilege of meeting Vinod Khosla, cofounder of SUN Microsystems and venture capitalist, who predicts that computers will largely supplant physicians in the future, at least in domains relying on access to data. As he puts it, “the core functions necessary for complex diagnoses, treatments, and monitoring will be driven by machine judgment instead of human judgment.”⁴

While the benefits of technology, especially in health care, are often oversold, I believe AI and related technologies will some day play a large role alongside physicians in the care of patients. However, for AI to deliver, we must first figure out how to collect and organize health care data so that computers are able to ingest, digest and use it in a purposeful way.

Note: Dr. Whitcomb is founder and advisor to Zato Health, which uses natural language processing and discovery technology in health care.

He is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.

References

1. Zimmer, Ben. Is It Time to Welcome Our New Computer Overlords?. The Atlantic. https://www.theatlantic.com/technology/archive/2011/02/is-it-time-to-welcome-our-new-computer-overlords/71388/. Accessed 23 Apr 2017.

2. Sanders, Dale. The MD Anderson / IBM Watson Announcement: What does it mean for machine learning in healthcare? Webinar. https://www.slideshare.net/healthcatalyst1/the-md-anderson-ibm-watson-announcement-what-does-it-mean-for-machine-learning-in-healthcare. Accessed 23 Apr 2017.

3. Baum, Stephanie. Venrock survey predicts a flight to quality for digital health investments. MedCity News. 12 Apr 2017. http://medcitynews.com/2017/04/venrock-survey-predicts-flight-quality-digital-health-investment/. Accessed 22 Apr 2017.

4. Khosla, Vinod. The Reinvention Of Medicine: Dr. Algorithm V0-7 And Beyond. TechCrunch. 22 Sept 2014. https://techcrunch.com/2014/09/22/the-reinvention-of-medicine-dr-algorithm-version-0-7-and-beyond/. Accessed 22 Apr 2017.

Welcome to the third and final day of HM17!

Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.

If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.

Welcome to the third and final day of HM17!

Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.

If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.

Welcome to the third and final day of HM17!

Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.

If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.

As I begin my year as SHM president, I continue to be energized by the opportunity to be part of an organization that has such a positive impact on our nation’s health care system. From the beginning of my medical career to now, never have I witnessed a health care movement quite like hospital medicine.

Even when I first arrived in Southern California as a pulmonary/critical-care physician in 1987, there were groups of physicians who had taken financial risk on populations of managed-care patients and were paid using an “alternative payment model” called capitation. One of the innovations they had utilized since the early ’80s to successfully manage their risk – and their patients’ – was to have dedicated inpatient physicians caring for their hospitalized patients 24/7, while most of their primary care partners managed the group’s patients in the outpatient setting.

Dr. Greeno is the incoming president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

As I begin my year as SHM president, I continue to be energized by the opportunity to be part of an organization that has such a positive impact on our nation’s health care system. From the beginning of my medical career to now, never have I witnessed a health care movement quite like hospital medicine.

Even when I first arrived in Southern California as a pulmonary/critical-care physician in 1987, there were groups of physicians who had taken financial risk on populations of managed-care patients and were paid using an “alternative payment model” called capitation. One of the innovations they had utilized since the early ’80s to successfully manage their risk – and their patients’ – was to have dedicated inpatient physicians caring for their hospitalized patients 24/7, while most of their primary care partners managed the group’s patients in the outpatient setting.

Dr. Greeno is the incoming president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

As I begin my year as SHM president, I continue to be energized by the opportunity to be part of an organization that has such a positive impact on our nation’s health care system. From the beginning of my medical career to now, never have I witnessed a health care movement quite like hospital medicine.

Even when I first arrived in Southern California as a pulmonary/critical-care physician in 1987, there were groups of physicians who had taken financial risk on populations of managed-care patients and were paid using an “alternative payment model” called capitation. One of the innovations they had utilized since the early ’80s to successfully manage their risk – and their patients’ – was to have dedicated inpatient physicians caring for their hospitalized patients 24/7, while most of their primary care partners managed the group’s patients in the outpatient setting.

Dr. Greeno is the incoming president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.