Perspectives in Hospital Medicine

Dramatic stories of disruptive physician behavior (DPB) appear occasionally in the news, such as the physician who shot and killed a colleague within hospital confines or the gynecologist who secretly took photographs using a camera disguised as a pen during pelvic examinations. More common in hospitals, however, are incidents of inappropriate behavior that may generate complaints from patients or other providers and at times snowball into administrative or legal challenges.

“Professionalism” is one of the six competencies listed by the Accreditation Council for Graduate Medical Education (ACGME)¹ and the American Board of Medical Specialties. Unfortunately, incidents of disruptive behavior can result in violation of the tenets of professionalism in the healthcare environment. These behaviors fall along a continuum ranging from outwardly aggressive and uncivil to overly passive and insidious. Although these behaviors can occur across all healthcare disciplines and settings and are not just limited to physicians, the behaviors of physicians often have a much greater impact on the healthcare system as a whole because of their positions of relative “power” within the system.² Hence, this problem requires greater awareness and education. In this context, the aim of this article is to discuss disruptive behaviors in physicians.

The AMA defines DPB as “personal conduct, verbal or physical that has the potential to negatively affect patient care or the ability to work with other members of the healthcare team.”³ The definition of DPB by the Joint Commission includes “all behaviors that undermine a culture of safety.”⁴ Both the Joint Commission and the AMA recognize the significance and patient safety implications of such behavior. Policy statements by both these organizations underscore the importance of confronting and remedying these potentially dangerous interpersonal behaviors.

Data regarding the prevalence of DPB have been inconsistent. One study estimated that 3%–5% of physicians demonstrate this behavior,⁵ whereas another study reported a DPB prevalence of 97% among physicians and nurses in the workplace.⁶ According to a 2004 survey of physician executives, more than 95% of them reported regular encounters of DPB.⁷

The etiology of such disruptive behaviors is multifactorial and complex. Explanations associated with ‘nature versus nurture’ have ranged from physician psychopathology to unhealthy modeling during training. Both extrinsic and intrinsic factors may also contribute to DPB. External stressors and negative experiences–professional and/or personal–can provoke disruptive behaviors. Overwork, fatigue, strife, and a dysfunctional environment that can arise in both work and home environments can contribute to the development of mental health problems. Stress, burnout, and depression have increasingly become prevalent among physicians and can play a significant role in causing impaired patterns of professional conduct.^{8, 9} These mental health problems can cause physicians to acquire maladaptive coping strategies such as substance abuse and drug or alcohol dependence. However, it is important to note that physician impairment and substance abuse are not the most frequent causes of DPB. In fact, fewer than 10% of physician behavior issues have been related to substance abuse.^{2, 5}

An institution’s organizational culture often has an impact on how DPB is addressed. Tolerance of such behavior can have far-reaching consequences. The central tenets of a “culture of safety and respect”–teamwork across disciplines and a blame-free environment in which every member of the healthcare team feels equally empowered to report errors and openly discuss safety issues–would be negatively impacted.

DPB can diminish the quality of care provided, increase the risk of medical errors, and adversely affect patient safety and satisfaction.^11-13 Such behavior can cause erosion of relationships and communication between individuals and contribute to a hostile work environment. For instance, nurses or trainees may be afraid to question a physician because of the fear of getting yelled at or being humiliated. Consequently, improperly written orders may be overlooked or a potentially “wrong-site” surgical procedure may not be questioned for fear of provoking a hostile response.

DPB can increase litigation risk and financial costs to institutions. Provider retention may be adversely affected; valued staff may leave hospitals and need to be replaced, and productivity may suffer. When physicians in training observe how their superiors model disruptive behaviors with impunity, a concerning problem that arises is that DPB becomes normalized in the workplace culture, especially if such behaviors are tolerated and result in a perceived gain.

Confrontation of DPB can be challenging without appropriate infrastructure. Healthcare facilities should have a fair system in place for reliable reporting and monitoring of DPB, including a complaints’ verification process, appeals process, and an option for fair hearing.

It is best to initially address the issue in a direct, timely, yet informal manner through counseling or a verbal warning. In several situations, such informal counseling opportunities create a mindful awareness of the problem and the problematic behavior ceases without the need for further action.

When informal intervention is either not appropriate (eg, if the alleged event involved an assault or other illegal behavior) or has already been offered in the past, more formal intervention is required. Institutional progressive disciplinary polices should be in place and adhered to. For example, repeat offenders may be issued written warnings or even temporary suspension of privileges.

Institutional resources such as human resources departments, office of general counsel, office of medical affairs, and the hospital’s medical board may be consulted. Some medical centers have “employee assistance programs” staffed with clinicians skilled in dealing with DPB. Individuals diagnosed with substance abuse or a mental health disorder may require consultation with mental health professionals.¹⁴

Special “Professionalism Committees” can be instituted and tasked with investigating complaints and making recommendations for the involvement of resources outside the institution, such as a state medical society.¹⁵

Although the vast majority of physicians are well-behaved, it is important to acknowledge that disruptive behaviors can occur in the healthcare environment. Such behaviors have a major impact on workplace culture and patient safety and must be recognized early. Hospital executives and leaders must ensure that appropriate interventions are undertaken—before the quality of patient care is affected and before lives are endangered.

Acknowledgment

The authors would like to thank Ansu John for providing editorial assistance with the manuscript.

Disclosures 

The authors have nothing to disclose (Conflict of Interest Form submitted as separate PDF document). Dr. Heitt consults with local hospitals, medical practices, and licensing boards regarding physicians and other healthcare practitioners who have been accused of engaging in disruptive behavior. In these situations he may be paid by the board, medical society, hospital, practice or the professional (patient).

Dramatic stories of disruptive physician behavior (DPB) appear occasionally in the news, such as the physician who shot and killed a colleague within hospital confines or the gynecologist who secretly took photographs using a camera disguised as a pen during pelvic examinations. More common in hospitals, however, are incidents of inappropriate behavior that may generate complaints from patients or other providers and at times snowball into administrative or legal challenges.

“Professionalism” is one of the six competencies listed by the Accreditation Council for Graduate Medical Education (ACGME)¹ and the American Board of Medical Specialties. Unfortunately, incidents of disruptive behavior can result in violation of the tenets of professionalism in the healthcare environment. These behaviors fall along a continuum ranging from outwardly aggressive and uncivil to overly passive and insidious. Although these behaviors can occur across all healthcare disciplines and settings and are not just limited to physicians, the behaviors of physicians often have a much greater impact on the healthcare system as a whole because of their positions of relative “power” within the system.² Hence, this problem requires greater awareness and education. In this context, the aim of this article is to discuss disruptive behaviors in physicians.

The AMA defines DPB as “personal conduct, verbal or physical that has the potential to negatively affect patient care or the ability to work with other members of the healthcare team.”³ The definition of DPB by the Joint Commission includes “all behaviors that undermine a culture of safety.”⁴ Both the Joint Commission and the AMA recognize the significance and patient safety implications of such behavior. Policy statements by both these organizations underscore the importance of confronting and remedying these potentially dangerous interpersonal behaviors.

Data regarding the prevalence of DPB have been inconsistent. One study estimated that 3%–5% of physicians demonstrate this behavior,⁵ whereas another study reported a DPB prevalence of 97% among physicians and nurses in the workplace.⁶ According to a 2004 survey of physician executives, more than 95% of them reported regular encounters of DPB.⁷

The etiology of such disruptive behaviors is multifactorial and complex. Explanations associated with ‘nature versus nurture’ have ranged from physician psychopathology to unhealthy modeling during training. Both extrinsic and intrinsic factors may also contribute to DPB. External stressors and negative experiences–professional and/or personal–can provoke disruptive behaviors. Overwork, fatigue, strife, and a dysfunctional environment that can arise in both work and home environments can contribute to the development of mental health problems. Stress, burnout, and depression have increasingly become prevalent among physicians and can play a significant role in causing impaired patterns of professional conduct.^{8, 9} These mental health problems can cause physicians to acquire maladaptive coping strategies such as substance abuse and drug or alcohol dependence. However, it is important to note that physician impairment and substance abuse are not the most frequent causes of DPB. In fact, fewer than 10% of physician behavior issues have been related to substance abuse.^{2, 5}

An institution’s organizational culture often has an impact on how DPB is addressed. Tolerance of such behavior can have far-reaching consequences. The central tenets of a “culture of safety and respect”–teamwork across disciplines and a blame-free environment in which every member of the healthcare team feels equally empowered to report errors and openly discuss safety issues–would be negatively impacted.

DPB can diminish the quality of care provided, increase the risk of medical errors, and adversely affect patient safety and satisfaction.^11-13 Such behavior can cause erosion of relationships and communication between individuals and contribute to a hostile work environment. For instance, nurses or trainees may be afraid to question a physician because of the fear of getting yelled at or being humiliated. Consequently, improperly written orders may be overlooked or a potentially “wrong-site” surgical procedure may not be questioned for fear of provoking a hostile response.

DPB can increase litigation risk and financial costs to institutions. Provider retention may be adversely affected; valued staff may leave hospitals and need to be replaced, and productivity may suffer. When physicians in training observe how their superiors model disruptive behaviors with impunity, a concerning problem that arises is that DPB becomes normalized in the workplace culture, especially if such behaviors are tolerated and result in a perceived gain.

Confrontation of DPB can be challenging without appropriate infrastructure. Healthcare facilities should have a fair system in place for reliable reporting and monitoring of DPB, including a complaints’ verification process, appeals process, and an option for fair hearing.

It is best to initially address the issue in a direct, timely, yet informal manner through counseling or a verbal warning. In several situations, such informal counseling opportunities create a mindful awareness of the problem and the problematic behavior ceases without the need for further action.

When informal intervention is either not appropriate (eg, if the alleged event involved an assault or other illegal behavior) or has already been offered in the past, more formal intervention is required. Institutional progressive disciplinary polices should be in place and adhered to. For example, repeat offenders may be issued written warnings or even temporary suspension of privileges.

Institutional resources such as human resources departments, office of general counsel, office of medical affairs, and the hospital’s medical board may be consulted. Some medical centers have “employee assistance programs” staffed with clinicians skilled in dealing with DPB. Individuals diagnosed with substance abuse or a mental health disorder may require consultation with mental health professionals.¹⁴

Special “Professionalism Committees” can be instituted and tasked with investigating complaints and making recommendations for the involvement of resources outside the institution, such as a state medical society.¹⁵

Although the vast majority of physicians are well-behaved, it is important to acknowledge that disruptive behaviors can occur in the healthcare environment. Such behaviors have a major impact on workplace culture and patient safety and must be recognized early. Hospital executives and leaders must ensure that appropriate interventions are undertaken—before the quality of patient care is affected and before lives are endangered.

Acknowledgment

The authors would like to thank Ansu John for providing editorial assistance with the manuscript.

Disclosures 

The authors have nothing to disclose (Conflict of Interest Form submitted as separate PDF document). Dr. Heitt consults with local hospitals, medical practices, and licensing boards regarding physicians and other healthcare practitioners who have been accused of engaging in disruptive behavior. In these situations he may be paid by the board, medical society, hospital, practice or the professional (patient).

Dramatic stories of disruptive physician behavior (DPB) appear occasionally in the news, such as the physician who shot and killed a colleague within hospital confines or the gynecologist who secretly took photographs using a camera disguised as a pen during pelvic examinations. More common in hospitals, however, are incidents of inappropriate behavior that may generate complaints from patients or other providers and at times snowball into administrative or legal challenges.

“Professionalism” is one of the six competencies listed by the Accreditation Council for Graduate Medical Education (ACGME)¹ and the American Board of Medical Specialties. Unfortunately, incidents of disruptive behavior can result in violation of the tenets of professionalism in the healthcare environment. These behaviors fall along a continuum ranging from outwardly aggressive and uncivil to overly passive and insidious. Although these behaviors can occur across all healthcare disciplines and settings and are not just limited to physicians, the behaviors of physicians often have a much greater impact on the healthcare system as a whole because of their positions of relative “power” within the system.² Hence, this problem requires greater awareness and education. In this context, the aim of this article is to discuss disruptive behaviors in physicians.

The AMA defines DPB as “personal conduct, verbal or physical that has the potential to negatively affect patient care or the ability to work with other members of the healthcare team.”³ The definition of DPB by the Joint Commission includes “all behaviors that undermine a culture of safety.”⁴ Both the Joint Commission and the AMA recognize the significance and patient safety implications of such behavior. Policy statements by both these organizations underscore the importance of confronting and remedying these potentially dangerous interpersonal behaviors.

Data regarding the prevalence of DPB have been inconsistent. One study estimated that 3%–5% of physicians demonstrate this behavior,⁵ whereas another study reported a DPB prevalence of 97% among physicians and nurses in the workplace.⁶ According to a 2004 survey of physician executives, more than 95% of them reported regular encounters of DPB.⁷

The etiology of such disruptive behaviors is multifactorial and complex. Explanations associated with ‘nature versus nurture’ have ranged from physician psychopathology to unhealthy modeling during training. Both extrinsic and intrinsic factors may also contribute to DPB. External stressors and negative experiences–professional and/or personal–can provoke disruptive behaviors. Overwork, fatigue, strife, and a dysfunctional environment that can arise in both work and home environments can contribute to the development of mental health problems. Stress, burnout, and depression have increasingly become prevalent among physicians and can play a significant role in causing impaired patterns of professional conduct.^{8, 9} These mental health problems can cause physicians to acquire maladaptive coping strategies such as substance abuse and drug or alcohol dependence. However, it is important to note that physician impairment and substance abuse are not the most frequent causes of DPB. In fact, fewer than 10% of physician behavior issues have been related to substance abuse.^{2, 5}

An institution’s organizational culture often has an impact on how DPB is addressed. Tolerance of such behavior can have far-reaching consequences. The central tenets of a “culture of safety and respect”–teamwork across disciplines and a blame-free environment in which every member of the healthcare team feels equally empowered to report errors and openly discuss safety issues–would be negatively impacted.

DPB can diminish the quality of care provided, increase the risk of medical errors, and adversely affect patient safety and satisfaction.^11-13 Such behavior can cause erosion of relationships and communication between individuals and contribute to a hostile work environment. For instance, nurses or trainees may be afraid to question a physician because of the fear of getting yelled at or being humiliated. Consequently, improperly written orders may be overlooked or a potentially “wrong-site” surgical procedure may not be questioned for fear of provoking a hostile response.

DPB can increase litigation risk and financial costs to institutions. Provider retention may be adversely affected; valued staff may leave hospitals and need to be replaced, and productivity may suffer. When physicians in training observe how their superiors model disruptive behaviors with impunity, a concerning problem that arises is that DPB becomes normalized in the workplace culture, especially if such behaviors are tolerated and result in a perceived gain.

Confrontation of DPB can be challenging without appropriate infrastructure. Healthcare facilities should have a fair system in place for reliable reporting and monitoring of DPB, including a complaints’ verification process, appeals process, and an option for fair hearing.

It is best to initially address the issue in a direct, timely, yet informal manner through counseling or a verbal warning. In several situations, such informal counseling opportunities create a mindful awareness of the problem and the problematic behavior ceases without the need for further action.

When informal intervention is either not appropriate (eg, if the alleged event involved an assault or other illegal behavior) or has already been offered in the past, more formal intervention is required. Institutional progressive disciplinary polices should be in place and adhered to. For example, repeat offenders may be issued written warnings or even temporary suspension of privileges.

Institutional resources such as human resources departments, office of general counsel, office of medical affairs, and the hospital’s medical board may be consulted. Some medical centers have “employee assistance programs” staffed with clinicians skilled in dealing with DPB. Individuals diagnosed with substance abuse or a mental health disorder may require consultation with mental health professionals.¹⁴

Special “Professionalism Committees” can be instituted and tasked with investigating complaints and making recommendations for the involvement of resources outside the institution, such as a state medical society.¹⁵

Although the vast majority of physicians are well-behaved, it is important to acknowledge that disruptive behaviors can occur in the healthcare environment. Such behaviors have a major impact on workplace culture and patient safety and must be recognized early. Hospital executives and leaders must ensure that appropriate interventions are undertaken—before the quality of patient care is affected and before lives are endangered.

Acknowledgment

The authors would like to thank Ansu John for providing editorial assistance with the manuscript.

Disclosures 

The authors have nothing to disclose (Conflict of Interest Form submitted as separate PDF document). Dr. Heitt consults with local hospitals, medical practices, and licensing boards regarding physicians and other healthcare practitioners who have been accused of engaging in disruptive behavior. In these situations he may be paid by the board, medical society, hospital, practice or the professional (patient).

Healthcare is a “dirty” business with widespread effects on the environment. In the US, healthcare is estimated to generate 9.8% of our greenhouse gases and 9% of our particulate matter emissions.¹ Hazardous wastes must be incinerated, emitting carbon dioxide, nitrogen oxides, and volatile substances into the atmosphere.² Similarly, hospitals are responsible for 7% of commercial water use in the US.³ Conventional water treatment systems are not designed to remove heavy metals, pharmaceuticals, and disinfectants in hospital wastewaters; these compounds have been detected in rivers and streams throughout the US.^4,5 Furthermore, pharmaceutical compounds such as antibiotics, anti-epileptics, and narcotics have even been isolated in our drinking water.⁵

As hospitalists, we are the directors of inpatient care, yet we only witness brief moments in the lives of our patients and the products we use for their care. For example, we are unaware of particulate matter emissions needed to power an extra imaging study or the contribution of unused materials to a growing landfill. However, pollution, including that from our clinical practice, is detrimental to human health in many ways. Exposure to particulate matter and toxic wastes has been linked to increased rates of reproductive and developmental disorders, cancer, and respiratory disease. ⁶ Particles <2.5 µm in diameter can diffuse through alveoli into the bloodstream, contributing to heart disease, stroke, and lung disease.⁷ Climate change has been linked to a wide range of adverse cardiovascular, respiratory, infectious, and mental health outcomes.^8,9 These examples of the health impacts of pollution are illustrative but not exhaustive.

The environmental impact of US healthcare accounts for an estimated 470,000 disability-adjusted life years lost; this figure is on par with the burden of preventable medical errors.¹ Clearly, change is necessary at all levels in the healthcare system to address our impact on human health. Fortunately, healthcare systems and hospital administrators have begun to address this issue. This perspective describes sustainability efforts in hospitals and healthcare systems and seeks to motivate hospitalists to build upon these efforts.

With the ability to affect change from the top down, health systems are playing an important role in healthcare’s environmental sustainability. Ambitiously, Kaiser Permanente outlined eight environmental stewardship goals, which include becoming net carbon positive and recycling, reusing, or composting 100% of their non-hazardous waste by 2025.¹⁰ The Cleveland Clinic has pledged to become carbon neutral within the next 10 years.¹¹ Other healthcare systems may follow suite. Many “green” interventions aimed at reducing waste and pollution also protect population health and reduce hospital operating costs.

From 2011 to 2015, a group of Boston Hospitals decreased energy use by 9.4% compared with a historical growth of 1.5% per year and saved over 15 million dollars.¹² Similarly, Virginia Mason reduced landfill waste by reprocessing single-use medical devices, thereby decreasing purchasing costs by $3 million.¹³ As part of a regional campaign to protect the St. Croix River, Hudson Hospital and Clinic in Wisconsin saved over $20,000 with new recycling and waste reduction programs.¹³ Notably, these programs not only benefit hospitals but also patients and payers by reducing costs of care.

These examples illustrate that a greener healthcare industry is achievable. Despite the potential benefits, sustainability efforts in US hospitals are the exception, not the rule, and the diffusion of such innovations must be encouraged from within.

In addition to the moral case for environmentally sustainable healthcare,^14,15 such efforts can also improve our quality of care. The conversation around healthcare waste has focused on costs. Yet, examining our waste from a new perspective may reveal new ways to increase the value of patient care while protecting population health. Our communities and families are not immune to the health impacts of pollution, including that generated by our industry. However, predicted effects of climate change including altered patterns of vector-borne disease and frequent hurricanes and forest fires are upon us, affecting our communities, hospitals, and health delivery enterprise today. These challenges represent educational, academic, and economic opportunities that hospitalists should embrace.

Education and Awareness

The first step to engagement is to promote awareness of the effects of healthcare waste. Physicians remain one of the most trusted sources of information about the health impacts of climate change.¹⁶ By educating ourselves, we can spread accurate knowledge to our patients and communities. Furthermore, we have the ability to advocate for our hospitals to follow institutions such as Kaiser Permanente and the Cleveland Clinic.

Given that hospitalists play a key role in educating students and residents, they are ideal vehicles for such dissemination. Education should begin in medical and nursing schools, where curricula detailing the importance and impact of healthcare pollution may be introduced. As hospitalists, we should champion such efforts.

Measurement and Amelioration

Second, resource use, waste production, and areas for improvement must be systematically quantified. At a national level, the Sustainable Development Unit of the National Health System (NHS) measures and reports water use, waste production, and energy consumption of the UK’s healthcare sector. Consequently, the NHS has surpassed their 2015 goal of reducing their carbon footprint by 10%.¹⁷ By establishing a baseline understanding of our carbon emissions, waste production, and water consumption, areas where physicians and hospitals can target improvement can similarly be identified.

Hospitalists appreciate the practical tradeoffs between clinical work and change efforts; thus, they are critical in establishing pragmatic policies. Physicians, often in collaboration with environmental engineers, have used evidence-based methods such as life-cycle analysis (LCA) to evaluate the environmental impacts of the pharmaceuticals and procedures that they use.^18-20 An LCA is a cost-benefit analysis that examines multiple parameters of a product, namely, emissions, water use, costs, and waste production, from production to disposal. For example, an LCA of disposable custom packs for hysterectomies, vaginal deliveries, and laryngeal masks found costs savings and environmental benefits from choosing reusable over single-use items and removing unnecessary materials such as extra towels in this setting. ^18-20 By considering the full life cycle of a procedure, LCAs reveal important information about the value and safety of care. LCAs, along with other sustainable design strategies, are tools that can provide hospitalists with new insights for quality improvement.

Public Reporting

Numerous physicians are known for educating their communities about the impacts of pollution on health. Recently, a pediatrician brought the presence of lead in Flint’s water supply to the public’s attention, instigating government action and policy change.²¹ A group called Utah Physicians for a Healthy Environment publishes online summaries of peer-reviewed information on air pollution and health. The Huma Lung Foundation led by a pulmonologist in Chennai, India, is working with a local radio station to report daily air quality measurements along with health advisories for the city.

We must now extend this paradigm to encompass transparency about healthcare’s practices and their impact on health. Indeed, the public is comfortable with this idea: a survey of 1011 respondents in the UK found that 92% indicated that the healthcare system should be environmentally sustainable.²² One idea may be a public-facing scorecard for hospitals, akin to publicly reported quality metrics. We can look to the example of the SDU and corporations such as Apple, which publicly report their carbon emissions, waste production, water use, and other metrics of their environmental impact. By galvanizing efforts to quantify and report our impact, hospitalists have the opportunity to be a role model for the industry and increase trust within their communities.

Individual Actions

What can a hospitalist do today? First, simple measures, like turning off idle electronics, recycling appropriately, or avoiding the use of unnecessary supplies or tests, are behavioral steps in the right direction. Second, just as education, goal setting, and feedback have met success in improving hand hygiene,²³ we must begin the hard work of developing programs to monitor our environmental impact. Individual hospitalist carbon scores may help intensify efforts and spur improvement. Finally, we should learn and celebrate each other’s success. Renewed focus on this topic with increased reporting of interventions and outcomes is needed.

As hospitalists, we must look within ourselves to protect our planet and advocate for solutions that assure a sustainable future. By recognizing that a healthy environment is crucial to human health, we can set an example for other industries and create a safer world for our patients. Eliminating the harm we do is the first step in this process.

Disclosures 

The authors have nothing to disclose.

Funding 

Dr. Chopra is supported by a Career Development Award from the Agency for Healthcare Quality and Research (1-K08-HS-022835-01).

Healthcare is a “dirty” business with widespread effects on the environment. In the US, healthcare is estimated to generate 9.8% of our greenhouse gases and 9% of our particulate matter emissions.¹ Hazardous wastes must be incinerated, emitting carbon dioxide, nitrogen oxides, and volatile substances into the atmosphere.² Similarly, hospitals are responsible for 7% of commercial water use in the US.³ Conventional water treatment systems are not designed to remove heavy metals, pharmaceuticals, and disinfectants in hospital wastewaters; these compounds have been detected in rivers and streams throughout the US.^4,5 Furthermore, pharmaceutical compounds such as antibiotics, anti-epileptics, and narcotics have even been isolated in our drinking water.⁵

As hospitalists, we are the directors of inpatient care, yet we only witness brief moments in the lives of our patients and the products we use for their care. For example, we are unaware of particulate matter emissions needed to power an extra imaging study or the contribution of unused materials to a growing landfill. However, pollution, including that from our clinical practice, is detrimental to human health in many ways. Exposure to particulate matter and toxic wastes has been linked to increased rates of reproductive and developmental disorders, cancer, and respiratory disease. ⁶ Particles <2.5 µm in diameter can diffuse through alveoli into the bloodstream, contributing to heart disease, stroke, and lung disease.⁷ Climate change has been linked to a wide range of adverse cardiovascular, respiratory, infectious, and mental health outcomes.^8,9 These examples of the health impacts of pollution are illustrative but not exhaustive.

The environmental impact of US healthcare accounts for an estimated 470,000 disability-adjusted life years lost; this figure is on par with the burden of preventable medical errors.¹ Clearly, change is necessary at all levels in the healthcare system to address our impact on human health. Fortunately, healthcare systems and hospital administrators have begun to address this issue. This perspective describes sustainability efforts in hospitals and healthcare systems and seeks to motivate hospitalists to build upon these efforts.

With the ability to affect change from the top down, health systems are playing an important role in healthcare’s environmental sustainability. Ambitiously, Kaiser Permanente outlined eight environmental stewardship goals, which include becoming net carbon positive and recycling, reusing, or composting 100% of their non-hazardous waste by 2025.¹⁰ The Cleveland Clinic has pledged to become carbon neutral within the next 10 years.¹¹ Other healthcare systems may follow suite. Many “green” interventions aimed at reducing waste and pollution also protect population health and reduce hospital operating costs.

From 2011 to 2015, a group of Boston Hospitals decreased energy use by 9.4% compared with a historical growth of 1.5% per year and saved over 15 million dollars.¹² Similarly, Virginia Mason reduced landfill waste by reprocessing single-use medical devices, thereby decreasing purchasing costs by $3 million.¹³ As part of a regional campaign to protect the St. Croix River, Hudson Hospital and Clinic in Wisconsin saved over $20,000 with new recycling and waste reduction programs.¹³ Notably, these programs not only benefit hospitals but also patients and payers by reducing costs of care.

These examples illustrate that a greener healthcare industry is achievable. Despite the potential benefits, sustainability efforts in US hospitals are the exception, not the rule, and the diffusion of such innovations must be encouraged from within.

In addition to the moral case for environmentally sustainable healthcare,^14,15 such efforts can also improve our quality of care. The conversation around healthcare waste has focused on costs. Yet, examining our waste from a new perspective may reveal new ways to increase the value of patient care while protecting population health. Our communities and families are not immune to the health impacts of pollution, including that generated by our industry. However, predicted effects of climate change including altered patterns of vector-borne disease and frequent hurricanes and forest fires are upon us, affecting our communities, hospitals, and health delivery enterprise today. These challenges represent educational, academic, and economic opportunities that hospitalists should embrace.

Education and Awareness

The first step to engagement is to promote awareness of the effects of healthcare waste. Physicians remain one of the most trusted sources of information about the health impacts of climate change.¹⁶ By educating ourselves, we can spread accurate knowledge to our patients and communities. Furthermore, we have the ability to advocate for our hospitals to follow institutions such as Kaiser Permanente and the Cleveland Clinic.

Given that hospitalists play a key role in educating students and residents, they are ideal vehicles for such dissemination. Education should begin in medical and nursing schools, where curricula detailing the importance and impact of healthcare pollution may be introduced. As hospitalists, we should champion such efforts.

Measurement and Amelioration

Second, resource use, waste production, and areas for improvement must be systematically quantified. At a national level, the Sustainable Development Unit of the National Health System (NHS) measures and reports water use, waste production, and energy consumption of the UK’s healthcare sector. Consequently, the NHS has surpassed their 2015 goal of reducing their carbon footprint by 10%.¹⁷ By establishing a baseline understanding of our carbon emissions, waste production, and water consumption, areas where physicians and hospitals can target improvement can similarly be identified.

Hospitalists appreciate the practical tradeoffs between clinical work and change efforts; thus, they are critical in establishing pragmatic policies. Physicians, often in collaboration with environmental engineers, have used evidence-based methods such as life-cycle analysis (LCA) to evaluate the environmental impacts of the pharmaceuticals and procedures that they use.^18-20 An LCA is a cost-benefit analysis that examines multiple parameters of a product, namely, emissions, water use, costs, and waste production, from production to disposal. For example, an LCA of disposable custom packs for hysterectomies, vaginal deliveries, and laryngeal masks found costs savings and environmental benefits from choosing reusable over single-use items and removing unnecessary materials such as extra towels in this setting. ^18-20 By considering the full life cycle of a procedure, LCAs reveal important information about the value and safety of care. LCAs, along with other sustainable design strategies, are tools that can provide hospitalists with new insights for quality improvement.

Public Reporting

Numerous physicians are known for educating their communities about the impacts of pollution on health. Recently, a pediatrician brought the presence of lead in Flint’s water supply to the public’s attention, instigating government action and policy change.²¹ A group called Utah Physicians for a Healthy Environment publishes online summaries of peer-reviewed information on air pollution and health. The Huma Lung Foundation led by a pulmonologist in Chennai, India, is working with a local radio station to report daily air quality measurements along with health advisories for the city.

We must now extend this paradigm to encompass transparency about healthcare’s practices and their impact on health. Indeed, the public is comfortable with this idea: a survey of 1011 respondents in the UK found that 92% indicated that the healthcare system should be environmentally sustainable.²² One idea may be a public-facing scorecard for hospitals, akin to publicly reported quality metrics. We can look to the example of the SDU and corporations such as Apple, which publicly report their carbon emissions, waste production, water use, and other metrics of their environmental impact. By galvanizing efforts to quantify and report our impact, hospitalists have the opportunity to be a role model for the industry and increase trust within their communities.

Individual Actions

What can a hospitalist do today? First, simple measures, like turning off idle electronics, recycling appropriately, or avoiding the use of unnecessary supplies or tests, are behavioral steps in the right direction. Second, just as education, goal setting, and feedback have met success in improving hand hygiene,²³ we must begin the hard work of developing programs to monitor our environmental impact. Individual hospitalist carbon scores may help intensify efforts and spur improvement. Finally, we should learn and celebrate each other’s success. Renewed focus on this topic with increased reporting of interventions and outcomes is needed.

As hospitalists, we must look within ourselves to protect our planet and advocate for solutions that assure a sustainable future. By recognizing that a healthy environment is crucial to human health, we can set an example for other industries and create a safer world for our patients. Eliminating the harm we do is the first step in this process.

Disclosures 

The authors have nothing to disclose.

Funding 

Dr. Chopra is supported by a Career Development Award from the Agency for Healthcare Quality and Research (1-K08-HS-022835-01).

Healthcare is a “dirty” business with widespread effects on the environment. In the US, healthcare is estimated to generate 9.8% of our greenhouse gases and 9% of our particulate matter emissions.¹ Hazardous wastes must be incinerated, emitting carbon dioxide, nitrogen oxides, and volatile substances into the atmosphere.² Similarly, hospitals are responsible for 7% of commercial water use in the US.³ Conventional water treatment systems are not designed to remove heavy metals, pharmaceuticals, and disinfectants in hospital wastewaters; these compounds have been detected in rivers and streams throughout the US.^4,5 Furthermore, pharmaceutical compounds such as antibiotics, anti-epileptics, and narcotics have even been isolated in our drinking water.⁵

As hospitalists, we are the directors of inpatient care, yet we only witness brief moments in the lives of our patients and the products we use for their care. For example, we are unaware of particulate matter emissions needed to power an extra imaging study or the contribution of unused materials to a growing landfill. However, pollution, including that from our clinical practice, is detrimental to human health in many ways. Exposure to particulate matter and toxic wastes has been linked to increased rates of reproductive and developmental disorders, cancer, and respiratory disease. ⁶ Particles <2.5 µm in diameter can diffuse through alveoli into the bloodstream, contributing to heart disease, stroke, and lung disease.⁷ Climate change has been linked to a wide range of adverse cardiovascular, respiratory, infectious, and mental health outcomes.^8,9 These examples of the health impacts of pollution are illustrative but not exhaustive.

The environmental impact of US healthcare accounts for an estimated 470,000 disability-adjusted life years lost; this figure is on par with the burden of preventable medical errors.¹ Clearly, change is necessary at all levels in the healthcare system to address our impact on human health. Fortunately, healthcare systems and hospital administrators have begun to address this issue. This perspective describes sustainability efforts in hospitals and healthcare systems and seeks to motivate hospitalists to build upon these efforts.

With the ability to affect change from the top down, health systems are playing an important role in healthcare’s environmental sustainability. Ambitiously, Kaiser Permanente outlined eight environmental stewardship goals, which include becoming net carbon positive and recycling, reusing, or composting 100% of their non-hazardous waste by 2025.¹⁰ The Cleveland Clinic has pledged to become carbon neutral within the next 10 years.¹¹ Other healthcare systems may follow suite. Many “green” interventions aimed at reducing waste and pollution also protect population health and reduce hospital operating costs.

From 2011 to 2015, a group of Boston Hospitals decreased energy use by 9.4% compared with a historical growth of 1.5% per year and saved over 15 million dollars.¹² Similarly, Virginia Mason reduced landfill waste by reprocessing single-use medical devices, thereby decreasing purchasing costs by $3 million.¹³ As part of a regional campaign to protect the St. Croix River, Hudson Hospital and Clinic in Wisconsin saved over $20,000 with new recycling and waste reduction programs.¹³ Notably, these programs not only benefit hospitals but also patients and payers by reducing costs of care.

These examples illustrate that a greener healthcare industry is achievable. Despite the potential benefits, sustainability efforts in US hospitals are the exception, not the rule, and the diffusion of such innovations must be encouraged from within.

In addition to the moral case for environmentally sustainable healthcare,^14,15 such efforts can also improve our quality of care. The conversation around healthcare waste has focused on costs. Yet, examining our waste from a new perspective may reveal new ways to increase the value of patient care while protecting population health. Our communities and families are not immune to the health impacts of pollution, including that generated by our industry. However, predicted effects of climate change including altered patterns of vector-borne disease and frequent hurricanes and forest fires are upon us, affecting our communities, hospitals, and health delivery enterprise today. These challenges represent educational, academic, and economic opportunities that hospitalists should embrace.

Education and Awareness

The first step to engagement is to promote awareness of the effects of healthcare waste. Physicians remain one of the most trusted sources of information about the health impacts of climate change.¹⁶ By educating ourselves, we can spread accurate knowledge to our patients and communities. Furthermore, we have the ability to advocate for our hospitals to follow institutions such as Kaiser Permanente and the Cleveland Clinic.

Given that hospitalists play a key role in educating students and residents, they are ideal vehicles for such dissemination. Education should begin in medical and nursing schools, where curricula detailing the importance and impact of healthcare pollution may be introduced. As hospitalists, we should champion such efforts.

Measurement and Amelioration

Second, resource use, waste production, and areas for improvement must be systematically quantified. At a national level, the Sustainable Development Unit of the National Health System (NHS) measures and reports water use, waste production, and energy consumption of the UK’s healthcare sector. Consequently, the NHS has surpassed their 2015 goal of reducing their carbon footprint by 10%.¹⁷ By establishing a baseline understanding of our carbon emissions, waste production, and water consumption, areas where physicians and hospitals can target improvement can similarly be identified.

Hospitalists appreciate the practical tradeoffs between clinical work and change efforts; thus, they are critical in establishing pragmatic policies. Physicians, often in collaboration with environmental engineers, have used evidence-based methods such as life-cycle analysis (LCA) to evaluate the environmental impacts of the pharmaceuticals and procedures that they use.^18-20 An LCA is a cost-benefit analysis that examines multiple parameters of a product, namely, emissions, water use, costs, and waste production, from production to disposal. For example, an LCA of disposable custom packs for hysterectomies, vaginal deliveries, and laryngeal masks found costs savings and environmental benefits from choosing reusable over single-use items and removing unnecessary materials such as extra towels in this setting. ^18-20 By considering the full life cycle of a procedure, LCAs reveal important information about the value and safety of care. LCAs, along with other sustainable design strategies, are tools that can provide hospitalists with new insights for quality improvement.

Public Reporting

Numerous physicians are known for educating their communities about the impacts of pollution on health. Recently, a pediatrician brought the presence of lead in Flint’s water supply to the public’s attention, instigating government action and policy change.²¹ A group called Utah Physicians for a Healthy Environment publishes online summaries of peer-reviewed information on air pollution and health. The Huma Lung Foundation led by a pulmonologist in Chennai, India, is working with a local radio station to report daily air quality measurements along with health advisories for the city.

We must now extend this paradigm to encompass transparency about healthcare’s practices and their impact on health. Indeed, the public is comfortable with this idea: a survey of 1011 respondents in the UK found that 92% indicated that the healthcare system should be environmentally sustainable.²² One idea may be a public-facing scorecard for hospitals, akin to publicly reported quality metrics. We can look to the example of the SDU and corporations such as Apple, which publicly report their carbon emissions, waste production, water use, and other metrics of their environmental impact. By galvanizing efforts to quantify and report our impact, hospitalists have the opportunity to be a role model for the industry and increase trust within their communities.

Individual Actions

What can a hospitalist do today? First, simple measures, like turning off idle electronics, recycling appropriately, or avoiding the use of unnecessary supplies or tests, are behavioral steps in the right direction. Second, just as education, goal setting, and feedback have met success in improving hand hygiene,²³ we must begin the hard work of developing programs to monitor our environmental impact. Individual hospitalist carbon scores may help intensify efforts and spur improvement. Finally, we should learn and celebrate each other’s success. Renewed focus on this topic with increased reporting of interventions and outcomes is needed.

As hospitalists, we must look within ourselves to protect our planet and advocate for solutions that assure a sustainable future. By recognizing that a healthy environment is crucial to human health, we can set an example for other industries and create a safer world for our patients. Eliminating the harm we do is the first step in this process.

Disclosures 

The authors have nothing to disclose.

Funding 

Dr. Chopra is supported by a Career Development Award from the Agency for Healthcare Quality and Research (1-K08-HS-022835-01).

To realize the vision of patient-centered care, efforts are focusing on engaging patients and “care partners,” often a family caregiver, by using patient-facing technologies.^1-4 Web-based patient portals linked to the electronic health record (EHR) provide patients and care partners with the ability to access personal health information online and to communicate with clinicians. In recent years, institutions have been increasing patient portal offerings to improve the patient experience, promote safety, and optimize healthcare delivery.^5-7

The adoption of patient portals has been driven by federal incentive programs (Meaningful Use), efforts by the Center for Medicare and Medicaid Services, and the Office of the National Coordinator for Health Information Technology to improve patient outcomes and the transition toward value-based reimbursement.^2,8,9 The vast majority of use has been in ambulatory settings; use for acute care is nascent at best.¹⁰ Among hospitalized patients, few bring an internet-enabled computer or mobile device to access personal health records online.¹¹ However, evidence suggests that care partners will use portals on behalf of acutely ill patients.⁴ As the Caregiver Advise, Record, Enable Act is implemented, hospitals will be required to identify patients’ care partners during hospitalization, inform them when the patient is ready for discharge, and provide self-management instructions during the transition home.¹² In this context, understanding how best to leverage acute care patient portals will be important to institutions, clinicians, and vendors.

The literature regarding acute care patient portals is rapidly growing.^4,10 Hospitalized patients have unmet information and communication needs, and hospital-based clinicians struggle to meet these needs in a timely manner.^13-15 In general, patients feel that using a mobile device to access personal health records has the potential to improve their experience.¹¹ Early studies suggest that acute care patient portals can promote patient-centered communication and collaboration during hospitalization, including in intensive care settings.^4,16,17 Furthermore, the use of acute care patient portals can improve perception of safety and quality, decrease anxiety, and increase understanding of health conditions.^3,14 Although early evidence is promising, considerable knowledge gaps exist regarding patient outcomes over the acute episode of care.^10,18

A clear area of interest is accessing acute care patient portals via mobile technology to engage patients during recovery from hospitalization.^4,11 Although we do not yet know whether use during care transitions will favorably impact outcomes, given the high rate of harm after discharge, this seems likely.¹⁹ The few studies evaluating the effect on validated measures of engagement (Patient Activation Measure) and hospital readmissions have not shown demonstrable improvement to date.^20,21 Clearly, optimizing acute care patient portals with regard to patient-clinician communication, as well as the type, timing, and format of information delivered, will be necessary to maximize value.^4,22

From the patient’s perspective, there is much we can learn.²³ Is the information that is presented pertinent, timely, and easy to understand? Will the use of portals detract from face-to-face interactions? Does greater transparency foster more accountability? Achieving an appropriate balance of digital health-information sharing for hospitalized patients is challenging given the sensitivity of patient data when diagnoses are uncertain and treatments are in flux.^4,24 These questions must be answered as hospitals implement acute care patient portals.

To start addressing knowledge gaps, we established a task force of 21 leading researchers, informatics and policy experts, and clinical leaders. The Acute Care Patient Portal Task Force was a subgroup of the Libretto Consortium, a collaboration of 4 academic medical centers established by the Gordon and Betty Moore Foundation to design, develop, and implement technologies to engage patients, care partners, and providers in preventing harm in hospital settings. Initially, we were challenged with assessing stakeholders’ perspectives from early adopter institutions. We learned that acute care patient portals must offer an integrated experience across care settings, humanize the patient-clinician relationship, enable equitable access, and align with institutional strategy to promote sustainability.¹⁹

Cognitive Support

The opportunities identified include acclimatizing and assimilating to the hospital environment (reviewing policies and patient rights) and facilitating self-education and preparation by linking to personal health information and providing structured guidance at transitions.⁴ For example, a care partner of an incapacitated patient may watch a video to orient to the intensive care unit, navigate educational content linked to the patient’s admission diagnosis (pneumonia) entered in the EHR, view the timing of an upcoming imaging study (chest computed tomography scan), and complete a standardized checklist prior to discharge.

The main challenges we identified include ensuring accuracy of hospital-, unit-, and patient-level information, addressing information overload, configuring notification and display settings to optimize the user experience, presenting information at an appropriate health literacy level,^4,21 and addressing security and privacy concerns when expanding access to family members.²⁴

Respect and Boundaries

Opportunities identified include supporting individual learning styles by using interactive features of mobile devices to improve comprehension for visual, auditory, and tactile learners and reinforcing learning through the use of various types of digital media.^25-27 For example, a visual learner may view a video tutorial for a newly prescribed medication. A tactile learner may prefer to use interactive graphical displays that exploit multidimensional touch capabilities of mobile devices to learn about active conditions or an upcoming procedure. An auditory learner may choose to use intelligent personal assistants to navigate their plan of care (“Hey Siri, what is my schedule for today?”). By addressing the learning preferences of patients and time constraints of clinicians, institutions can use acute care patient portals to promote more respectful interactions and collaborative decision-making during important care processes, such as obtaining surgical consent.^28,29

We also identified opportunities to facilitate personalization by tailoring educational content and by enabling the use of patient-generated health data collected from wearable devices. For example, patients may prefer to interact with a virtual advocate to review discharge instructions (“Louis” in Project Re-Engineered Discharge) when personalized to their demographics and health literacy level.^30-32 Patients may choose to upload step counts from wearable devices so that clinicians can monitor activity goals in preparation for discharge and while recovering afterwards. When supported in these ways, acute care patient portals allow patients to have more meaningful interactions with clinicians about diagnoses, treatments, prognosis, and goals for recovery.

The main challenges we identified include balancing interactions with technology and clinicians, ensuring clinicians understand how patients from different socioeconomic backgrounds use existing and newer technology to enhance self-management, assessing health and technology literacy, and understanding individual preferences for sharing patient-generated health data. Importantly, we must remain vigilant that patients will express concern about overdependence on technology, especially if it detracts from in-person interaction; our panelists emphasized that technology should never replace “human touch.”

Patient and Family Empowerment

The opportunities identified include promoting patient-centered communication by supporting a real-time and asynchronous dialogue among patients, care partners, and care team members (including ambulatory clinicians) while minimizing conversational silos^4,33; displaying names, roles, and pictures of all care team members^4,34; fostering transparency by sharing clinician documentation in progress notes and sign-outs³⁵; ensuring accountability for a single plan of care spanning shift changes and handoffs, and providing a mechanism to enable real-time feedback.

Hospitalization can be a vulnerable and isolating experience, perpetuated by a lack of timely and coordinated communication with the care team. We identified opportunities to mitigate anxiety by promoting shared understanding when questions require input from multiple clinicians, when team members change, or when patients wish to communicate with their longitudinal ambulatory providers.^4,34 For example, inviting patients to review clinicians’ progress notes should stimulate more open and meaningful communication.³⁵ Furthermore, requesting that patients state their wishes, preferences, and goals could improve overall concordance with care team members.^36,37 Empowering patients and care partners to voice their concerns, particularly those related to miscommunication, may mitigate harm propagated by handoffs, shift work, and weekend coverage.^38,39 While reporting safety concerns represents a novel mechanism to augment medical-error reporting by clinicians alone,^23,40 this strategy will be most effective when aligned with standardized communication initiatives (I-PASS) that have been proven to reduce medical errors and preventable adverse events and are being implemented nationally.⁴¹ Finally, by leveraging tools that facilitate instantaneous feedback, patients can be empowered to react to their plan (ranking skilled nursing facility options) as it is developed.

The main challenges we identified include managing expectations regarding the use of communication tools, accurately and reliably identifying care team members in the EHR,³⁴ acknowledging patients as equal partners, ensuring patients receive a consistent message about diagnoses and therapies during handoffs and when multiple consultants have conflicting opinions about the plan,³⁷ and addressing patient concerns fairly and respectfully.

In summary, the patient-centered themes we identified serve as guiding principles for institutions, clinicians, and vendors who wish to use patient portals to improve the acute and postacute care patient experience. One central message resonates: Patients do not simply want access to their health information and the ability to communicate with the clinicians who furnish this information; they want to feel supported, respected, and empowered when doing so. It is only through partnership with patients and their advocates that we can fully realize the impact of digital technologies when patients are in their most vulnerable state.

Acknowledgments

The authors thank their colleagues and the patient and family advocates who contributed to this body of work as part of the Acute Care Patient Portal Task Force and conference: Brittany Couture; Ronen Rozenblum, PhD, MPH; Jennifer Prey, MPhil, MS, PhD; Kristin O’Reilly, RN, BSN, MPH; Patricia Q. Bourie, RN, MS, Cindy Dwyer, RN, BSN,S; Ryan Greysen, MD, MHS, MA; Jeffery Smith, MPP; Michael Gropper, MD, PhD; Patricia Dykes, RN, PhD; Martha B. Carnie; Jeffrey W. Mello; and Jane Webster.

Disclosure

Anuj K. Dalal, MD, David W. Bates, MD, MSc, and Sarah Collins, RN, PhD, are responsible for the conception or design of the work; acquisition, analysis, or interpretation of data; drafting the work or revising it critically for important intellectual content; and final approval of the version to be published. The authors agree to be accountable for all aspects of the work and to ensure that questions related to the accuracy or integrity of the work are appropriately investigated and resolved. This work was supported by a grant from the Gordon and Betty Moore Foundation ([GBMF] #4993). GBMF had no role in the design or conduct of the study; the collection, analysis, or interpretation of data; or preparation or review of the manuscript. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of GBMF. The authors report no conflicts of interest.

To realize the vision of patient-centered care, efforts are focusing on engaging patients and “care partners,” often a family caregiver, by using patient-facing technologies.^1-4 Web-based patient portals linked to the electronic health record (EHR) provide patients and care partners with the ability to access personal health information online and to communicate with clinicians. In recent years, institutions have been increasing patient portal offerings to improve the patient experience, promote safety, and optimize healthcare delivery.^5-7

The adoption of patient portals has been driven by federal incentive programs (Meaningful Use), efforts by the Center for Medicare and Medicaid Services, and the Office of the National Coordinator for Health Information Technology to improve patient outcomes and the transition toward value-based reimbursement.^2,8,9 The vast majority of use has been in ambulatory settings; use for acute care is nascent at best.¹⁰ Among hospitalized patients, few bring an internet-enabled computer or mobile device to access personal health records online.¹¹ However, evidence suggests that care partners will use portals on behalf of acutely ill patients.⁴ As the Caregiver Advise, Record, Enable Act is implemented, hospitals will be required to identify patients’ care partners during hospitalization, inform them when the patient is ready for discharge, and provide self-management instructions during the transition home.¹² In this context, understanding how best to leverage acute care patient portals will be important to institutions, clinicians, and vendors.

The literature regarding acute care patient portals is rapidly growing.^4,10 Hospitalized patients have unmet information and communication needs, and hospital-based clinicians struggle to meet these needs in a timely manner.^13-15 In general, patients feel that using a mobile device to access personal health records has the potential to improve their experience.¹¹ Early studies suggest that acute care patient portals can promote patient-centered communication and collaboration during hospitalization, including in intensive care settings.^4,16,17 Furthermore, the use of acute care patient portals can improve perception of safety and quality, decrease anxiety, and increase understanding of health conditions.^3,14 Although early evidence is promising, considerable knowledge gaps exist regarding patient outcomes over the acute episode of care.^10,18

A clear area of interest is accessing acute care patient portals via mobile technology to engage patients during recovery from hospitalization.^4,11 Although we do not yet know whether use during care transitions will favorably impact outcomes, given the high rate of harm after discharge, this seems likely.¹⁹ The few studies evaluating the effect on validated measures of engagement (Patient Activation Measure) and hospital readmissions have not shown demonstrable improvement to date.^20,21 Clearly, optimizing acute care patient portals with regard to patient-clinician communication, as well as the type, timing, and format of information delivered, will be necessary to maximize value.^4,22

From the patient’s perspective, there is much we can learn.²³ Is the information that is presented pertinent, timely, and easy to understand? Will the use of portals detract from face-to-face interactions? Does greater transparency foster more accountability? Achieving an appropriate balance of digital health-information sharing for hospitalized patients is challenging given the sensitivity of patient data when diagnoses are uncertain and treatments are in flux.^4,24 These questions must be answered as hospitals implement acute care patient portals.

To start addressing knowledge gaps, we established a task force of 21 leading researchers, informatics and policy experts, and clinical leaders. The Acute Care Patient Portal Task Force was a subgroup of the Libretto Consortium, a collaboration of 4 academic medical centers established by the Gordon and Betty Moore Foundation to design, develop, and implement technologies to engage patients, care partners, and providers in preventing harm in hospital settings. Initially, we were challenged with assessing stakeholders’ perspectives from early adopter institutions. We learned that acute care patient portals must offer an integrated experience across care settings, humanize the patient-clinician relationship, enable equitable access, and align with institutional strategy to promote sustainability.¹⁹

Cognitive Support

The opportunities identified include acclimatizing and assimilating to the hospital environment (reviewing policies and patient rights) and facilitating self-education and preparation by linking to personal health information and providing structured guidance at transitions.⁴ For example, a care partner of an incapacitated patient may watch a video to orient to the intensive care unit, navigate educational content linked to the patient’s admission diagnosis (pneumonia) entered in the EHR, view the timing of an upcoming imaging study (chest computed tomography scan), and complete a standardized checklist prior to discharge.

The main challenges we identified include ensuring accuracy of hospital-, unit-, and patient-level information, addressing information overload, configuring notification and display settings to optimize the user experience, presenting information at an appropriate health literacy level,^4,21 and addressing security and privacy concerns when expanding access to family members.²⁴

Respect and Boundaries

Opportunities identified include supporting individual learning styles by using interactive features of mobile devices to improve comprehension for visual, auditory, and tactile learners and reinforcing learning through the use of various types of digital media.^25-27 For example, a visual learner may view a video tutorial for a newly prescribed medication. A tactile learner may prefer to use interactive graphical displays that exploit multidimensional touch capabilities of mobile devices to learn about active conditions or an upcoming procedure. An auditory learner may choose to use intelligent personal assistants to navigate their plan of care (“Hey Siri, what is my schedule for today?”). By addressing the learning preferences of patients and time constraints of clinicians, institutions can use acute care patient portals to promote more respectful interactions and collaborative decision-making during important care processes, such as obtaining surgical consent.^28,29

We also identified opportunities to facilitate personalization by tailoring educational content and by enabling the use of patient-generated health data collected from wearable devices. For example, patients may prefer to interact with a virtual advocate to review discharge instructions (“Louis” in Project Re-Engineered Discharge) when personalized to their demographics and health literacy level.^30-32 Patients may choose to upload step counts from wearable devices so that clinicians can monitor activity goals in preparation for discharge and while recovering afterwards. When supported in these ways, acute care patient portals allow patients to have more meaningful interactions with clinicians about diagnoses, treatments, prognosis, and goals for recovery.

The main challenges we identified include balancing interactions with technology and clinicians, ensuring clinicians understand how patients from different socioeconomic backgrounds use existing and newer technology to enhance self-management, assessing health and technology literacy, and understanding individual preferences for sharing patient-generated health data. Importantly, we must remain vigilant that patients will express concern about overdependence on technology, especially if it detracts from in-person interaction; our panelists emphasized that technology should never replace “human touch.”

Patient and Family Empowerment

The opportunities identified include promoting patient-centered communication by supporting a real-time and asynchronous dialogue among patients, care partners, and care team members (including ambulatory clinicians) while minimizing conversational silos^4,33; displaying names, roles, and pictures of all care team members^4,34; fostering transparency by sharing clinician documentation in progress notes and sign-outs³⁵; ensuring accountability for a single plan of care spanning shift changes and handoffs, and providing a mechanism to enable real-time feedback.

Hospitalization can be a vulnerable and isolating experience, perpetuated by a lack of timely and coordinated communication with the care team. We identified opportunities to mitigate anxiety by promoting shared understanding when questions require input from multiple clinicians, when team members change, or when patients wish to communicate with their longitudinal ambulatory providers.^4,34 For example, inviting patients to review clinicians’ progress notes should stimulate more open and meaningful communication.³⁵ Furthermore, requesting that patients state their wishes, preferences, and goals could improve overall concordance with care team members.^36,37 Empowering patients and care partners to voice their concerns, particularly those related to miscommunication, may mitigate harm propagated by handoffs, shift work, and weekend coverage.^38,39 While reporting safety concerns represents a novel mechanism to augment medical-error reporting by clinicians alone,^23,40 this strategy will be most effective when aligned with standardized communication initiatives (I-PASS) that have been proven to reduce medical errors and preventable adverse events and are being implemented nationally.⁴¹ Finally, by leveraging tools that facilitate instantaneous feedback, patients can be empowered to react to their plan (ranking skilled nursing facility options) as it is developed.

The main challenges we identified include managing expectations regarding the use of communication tools, accurately and reliably identifying care team members in the EHR,³⁴ acknowledging patients as equal partners, ensuring patients receive a consistent message about diagnoses and therapies during handoffs and when multiple consultants have conflicting opinions about the plan,³⁷ and addressing patient concerns fairly and respectfully.

In summary, the patient-centered themes we identified serve as guiding principles for institutions, clinicians, and vendors who wish to use patient portals to improve the acute and postacute care patient experience. One central message resonates: Patients do not simply want access to their health information and the ability to communicate with the clinicians who furnish this information; they want to feel supported, respected, and empowered when doing so. It is only through partnership with patients and their advocates that we can fully realize the impact of digital technologies when patients are in their most vulnerable state.

Acknowledgments

The authors thank their colleagues and the patient and family advocates who contributed to this body of work as part of the Acute Care Patient Portal Task Force and conference: Brittany Couture; Ronen Rozenblum, PhD, MPH; Jennifer Prey, MPhil, MS, PhD; Kristin O’Reilly, RN, BSN, MPH; Patricia Q. Bourie, RN, MS, Cindy Dwyer, RN, BSN,S; Ryan Greysen, MD, MHS, MA; Jeffery Smith, MPP; Michael Gropper, MD, PhD; Patricia Dykes, RN, PhD; Martha B. Carnie; Jeffrey W. Mello; and Jane Webster.

Disclosure

Anuj K. Dalal, MD, David W. Bates, MD, MSc, and Sarah Collins, RN, PhD, are responsible for the conception or design of the work; acquisition, analysis, or interpretation of data; drafting the work or revising it critically for important intellectual content; and final approval of the version to be published. The authors agree to be accountable for all aspects of the work and to ensure that questions related to the accuracy or integrity of the work are appropriately investigated and resolved. This work was supported by a grant from the Gordon and Betty Moore Foundation ([GBMF] #4993). GBMF had no role in the design or conduct of the study; the collection, analysis, or interpretation of data; or preparation or review of the manuscript. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of GBMF. The authors report no conflicts of interest.

To realize the vision of patient-centered care, efforts are focusing on engaging patients and “care partners,” often a family caregiver, by using patient-facing technologies.^1-4 Web-based patient portals linked to the electronic health record (EHR) provide patients and care partners with the ability to access personal health information online and to communicate with clinicians. In recent years, institutions have been increasing patient portal offerings to improve the patient experience, promote safety, and optimize healthcare delivery.^5-7

The adoption of patient portals has been driven by federal incentive programs (Meaningful Use), efforts by the Center for Medicare and Medicaid Services, and the Office of the National Coordinator for Health Information Technology to improve patient outcomes and the transition toward value-based reimbursement.^2,8,9 The vast majority of use has been in ambulatory settings; use for acute care is nascent at best.¹⁰ Among hospitalized patients, few bring an internet-enabled computer or mobile device to access personal health records online.¹¹ However, evidence suggests that care partners will use portals on behalf of acutely ill patients.⁴ As the Caregiver Advise, Record, Enable Act is implemented, hospitals will be required to identify patients’ care partners during hospitalization, inform them when the patient is ready for discharge, and provide self-management instructions during the transition home.¹² In this context, understanding how best to leverage acute care patient portals will be important to institutions, clinicians, and vendors.

The literature regarding acute care patient portals is rapidly growing.^4,10 Hospitalized patients have unmet information and communication needs, and hospital-based clinicians struggle to meet these needs in a timely manner.^13-15 In general, patients feel that using a mobile device to access personal health records has the potential to improve their experience.¹¹ Early studies suggest that acute care patient portals can promote patient-centered communication and collaboration during hospitalization, including in intensive care settings.^4,16,17 Furthermore, the use of acute care patient portals can improve perception of safety and quality, decrease anxiety, and increase understanding of health conditions.^3,14 Although early evidence is promising, considerable knowledge gaps exist regarding patient outcomes over the acute episode of care.^10,18

A clear area of interest is accessing acute care patient portals via mobile technology to engage patients during recovery from hospitalization.^4,11 Although we do not yet know whether use during care transitions will favorably impact outcomes, given the high rate of harm after discharge, this seems likely.¹⁹ The few studies evaluating the effect on validated measures of engagement (Patient Activation Measure) and hospital readmissions have not shown demonstrable improvement to date.^20,21 Clearly, optimizing acute care patient portals with regard to patient-clinician communication, as well as the type, timing, and format of information delivered, will be necessary to maximize value.^4,22

From the patient’s perspective, there is much we can learn.²³ Is the information that is presented pertinent, timely, and easy to understand? Will the use of portals detract from face-to-face interactions? Does greater transparency foster more accountability? Achieving an appropriate balance of digital health-information sharing for hospitalized patients is challenging given the sensitivity of patient data when diagnoses are uncertain and treatments are in flux.^4,24 These questions must be answered as hospitals implement acute care patient portals.

To start addressing knowledge gaps, we established a task force of 21 leading researchers, informatics and policy experts, and clinical leaders. The Acute Care Patient Portal Task Force was a subgroup of the Libretto Consortium, a collaboration of 4 academic medical centers established by the Gordon and Betty Moore Foundation to design, develop, and implement technologies to engage patients, care partners, and providers in preventing harm in hospital settings. Initially, we were challenged with assessing stakeholders’ perspectives from early adopter institutions. We learned that acute care patient portals must offer an integrated experience across care settings, humanize the patient-clinician relationship, enable equitable access, and align with institutional strategy to promote sustainability.¹⁹

Cognitive Support

The opportunities identified include acclimatizing and assimilating to the hospital environment (reviewing policies and patient rights) and facilitating self-education and preparation by linking to personal health information and providing structured guidance at transitions.⁴ For example, a care partner of an incapacitated patient may watch a video to orient to the intensive care unit, navigate educational content linked to the patient’s admission diagnosis (pneumonia) entered in the EHR, view the timing of an upcoming imaging study (chest computed tomography scan), and complete a standardized checklist prior to discharge.

The main challenges we identified include ensuring accuracy of hospital-, unit-, and patient-level information, addressing information overload, configuring notification and display settings to optimize the user experience, presenting information at an appropriate health literacy level,^4,21 and addressing security and privacy concerns when expanding access to family members.²⁴

Respect and Boundaries

Opportunities identified include supporting individual learning styles by using interactive features of mobile devices to improve comprehension for visual, auditory, and tactile learners and reinforcing learning through the use of various types of digital media.^25-27 For example, a visual learner may view a video tutorial for a newly prescribed medication. A tactile learner may prefer to use interactive graphical displays that exploit multidimensional touch capabilities of mobile devices to learn about active conditions or an upcoming procedure. An auditory learner may choose to use intelligent personal assistants to navigate their plan of care (“Hey Siri, what is my schedule for today?”). By addressing the learning preferences of patients and time constraints of clinicians, institutions can use acute care patient portals to promote more respectful interactions and collaborative decision-making during important care processes, such as obtaining surgical consent.^28,29

We also identified opportunities to facilitate personalization by tailoring educational content and by enabling the use of patient-generated health data collected from wearable devices. For example, patients may prefer to interact with a virtual advocate to review discharge instructions (“Louis” in Project Re-Engineered Discharge) when personalized to their demographics and health literacy level.^30-32 Patients may choose to upload step counts from wearable devices so that clinicians can monitor activity goals in preparation for discharge and while recovering afterwards. When supported in these ways, acute care patient portals allow patients to have more meaningful interactions with clinicians about diagnoses, treatments, prognosis, and goals for recovery.

The main challenges we identified include balancing interactions with technology and clinicians, ensuring clinicians understand how patients from different socioeconomic backgrounds use existing and newer technology to enhance self-management, assessing health and technology literacy, and understanding individual preferences for sharing patient-generated health data. Importantly, we must remain vigilant that patients will express concern about overdependence on technology, especially if it detracts from in-person interaction; our panelists emphasized that technology should never replace “human touch.”

Patient and Family Empowerment

The opportunities identified include promoting patient-centered communication by supporting a real-time and asynchronous dialogue among patients, care partners, and care team members (including ambulatory clinicians) while minimizing conversational silos^4,33; displaying names, roles, and pictures of all care team members^4,34; fostering transparency by sharing clinician documentation in progress notes and sign-outs³⁵; ensuring accountability for a single plan of care spanning shift changes and handoffs, and providing a mechanism to enable real-time feedback.

Hospitalization can be a vulnerable and isolating experience, perpetuated by a lack of timely and coordinated communication with the care team. We identified opportunities to mitigate anxiety by promoting shared understanding when questions require input from multiple clinicians, when team members change, or when patients wish to communicate with their longitudinal ambulatory providers.^4,34 For example, inviting patients to review clinicians’ progress notes should stimulate more open and meaningful communication.³⁵ Furthermore, requesting that patients state their wishes, preferences, and goals could improve overall concordance with care team members.^36,37 Empowering patients and care partners to voice their concerns, particularly those related to miscommunication, may mitigate harm propagated by handoffs, shift work, and weekend coverage.^38,39 While reporting safety concerns represents a novel mechanism to augment medical-error reporting by clinicians alone,^23,40 this strategy will be most effective when aligned with standardized communication initiatives (I-PASS) that have been proven to reduce medical errors and preventable adverse events and are being implemented nationally.⁴¹ Finally, by leveraging tools that facilitate instantaneous feedback, patients can be empowered to react to their plan (ranking skilled nursing facility options) as it is developed.

The main challenges we identified include managing expectations regarding the use of communication tools, accurately and reliably identifying care team members in the EHR,³⁴ acknowledging patients as equal partners, ensuring patients receive a consistent message about diagnoses and therapies during handoffs and when multiple consultants have conflicting opinions about the plan,³⁷ and addressing patient concerns fairly and respectfully.

In summary, the patient-centered themes we identified serve as guiding principles for institutions, clinicians, and vendors who wish to use patient portals to improve the acute and postacute care patient experience. One central message resonates: Patients do not simply want access to their health information and the ability to communicate with the clinicians who furnish this information; they want to feel supported, respected, and empowered when doing so. It is only through partnership with patients and their advocates that we can fully realize the impact of digital technologies when patients are in their most vulnerable state.

Acknowledgments

The authors thank their colleagues and the patient and family advocates who contributed to this body of work as part of the Acute Care Patient Portal Task Force and conference: Brittany Couture; Ronen Rozenblum, PhD, MPH; Jennifer Prey, MPhil, MS, PhD; Kristin O’Reilly, RN, BSN, MPH; Patricia Q. Bourie, RN, MS, Cindy Dwyer, RN, BSN,S; Ryan Greysen, MD, MHS, MA; Jeffery Smith, MPP; Michael Gropper, MD, PhD; Patricia Dykes, RN, PhD; Martha B. Carnie; Jeffrey W. Mello; and Jane Webster.

Disclosure

Anuj K. Dalal, MD, David W. Bates, MD, MSc, and Sarah Collins, RN, PhD, are responsible for the conception or design of the work; acquisition, analysis, or interpretation of data; drafting the work or revising it critically for important intellectual content; and final approval of the version to be published. The authors agree to be accountable for all aspects of the work and to ensure that questions related to the accuracy or integrity of the work are appropriately investigated and resolved. This work was supported by a grant from the Gordon and Betty Moore Foundation ([GBMF] #4993). GBMF had no role in the design or conduct of the study; the collection, analysis, or interpretation of data; or preparation or review of the manuscript. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of GBMF. The authors report no conflicts of interest.

Hospital readmission rates are a consequential and contentious measure of hospital quality. Readmissions within 30 days of hospital discharge are part of the Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing Program and are publicly reported. Hospital-wide readmissions and condition-specific readmissions are heavily weighted by US News & World Report in its hospital rankings and in the new CMS Five-Star Quality Rating System.¹ However, clinicians and researchers question the construct validity of current readmission measures.^2,3

The focus on readmissions began in 2009 when Jencks et al.⁴ reported that 20% of Medicare patients were readmitted within 30 days after hospital discharge. Policy makers embraced readmission reduction, assuming that a hospital readmission so soon after discharge reflected poor quality of hospital care and that, with focused efforts, hospitals could reduce readmissions and save CMS money. In 2010, the Affordable Care Act introduced an initiative to reduce readmissions and, in 2012, the Hospital Readmission Reduction Program was implemented, financially penalizing hospitals with higher-than-expected readmission rates for patients hospitalized with principal diagnoses of heart failure, myocardial infarction, and pneumonia.⁵ Readmission measures have since proliferated and now include pay-for-performance metrics for hospitalizations for chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting, and total hip or knee arthroplasty. Measures are also reported for stroke patients and for “hospital-wide readmissions,” a catch-all measure intended to capture readmission rates across most diagnoses, with various exclusions intended to prevent counting planned readmissions (eg, hospitalization for cholecystectomy following a hospitalization for cholecystitis). These measures use claims data to construct hierarchical regression models at the patient and hospital levels, assuming that variation among readmission rates are due to hospital quality effects. The goal of this approach is to level the playing field to avoid penalizing hospitals for caring for sicker patients who are at higher risk for readmission for reasons unrelated to hospital care. Yet hospital readmissions are influenced by a complex set of variables that go well beyond hospital care, some of which may be better captured by existing models than others. Below we review several potential biases in the hospital readmission measures and offer policy recommendations to improve the accuracy of these measures.

Variation in a quality measure is influenced by the quality of the underlying data, the mix of patients served, bias in the performance measure, and the degree of systemic or random error.⁶ Hospital readmission rates are subject to multiple sources of variation, and true differences in the quality of care are often a much smaller source of this variation. A recent analysis of patient readmissions following general surgery found that the majority were unrelated to suboptimal medical care.⁷ Consider 3 scenarios in which a patient with COPD is readmitted 22 days after discharge. In hospital 1, the patient was discharged without a prescription for a steroid inhaler. In hospital 2, the patient was discharged on a steroid inhaler, filled the prescription, and elected not to use it. In hospital 3, the patient was discharged on a steroid inhaler and was provided medical assistance to fill the prescription but still could not afford the $15 copay. In all 3 scenarios, the hospital would be equally culpable under the current readmission measures, suffering financial and reputational penalties.

Yet the hospitals in these scenarios are not equally culpable. Variation in the mix of patients and bias in the measure impacted performance. Hospital 1 should clearly be held accountable for the readmission. In the cases of hospitals 2 and 3, the situations are more nuanced. More education about COPD, financial investment by the hospital to cover a copay, or a different transitional care approach may have increased the likelihood of patient compliance, but, ultimately, hospitals 2 and 3 were impacted by personal health behaviors and access to public health services and financial assistance, and the readmissions were less within their control.⁸

To be valid, hospital readmission measures would need to ensure that all hospitals are similar in patient characteristics and in the need for an availability of public health services. Yet these factors vary among hospitals and cannot be accounted for by models that rely exclusively on patient-level variables, such as the nature and severity of illness. As a result, the existing readmission measures are biased against certain types of hospitals. Hospitals that treat a greater proportion of patients who are socioeconomically disadvantaged; who lack access to primary care, medical assistance, or public health programs; and who have substance abuse and mental health issues will have higher readmission rates. Hospitals that care for patients who fail initial treatments and require referral for complex care will also have higher readmission rates. These types of patients are not randomly distributed throughout our healthcare system. They are clustered at rural hospitals in underserved areas, certain urban health systems, safety net hospitals, and academic health centers. It is not surprising that readmission penalties have most severely impacted large academic hospitals that care for disadvantaged populations.² These penalties may have unintended consequences, reducing a hospital’s willingness to care for disadvantaged populations.

While these biases may unfairly harm hospitals caring for disadvantaged patients, the readmission measures may also indirectly harm patients. Low hospital readmission rates are not associated with reduced mortality and, in some instances, track with higher mortality.^9-11 This may result from measurement factors (patients who die cannot be readmitted), from neighborhood socioeconomic status (SES) factors that may impact readmissions more,¹² or from actual patient harm (some patients need acute care following discharge and may have worse outcomes if that care is delayed).¹¹ Doctors have long recognized this potential risk; empiric evidence now supports them. While mortality measures may also be impacted by sociodemographic variables,¹³ whether to adjust for SES should be defined by the purpose of the measure. If the measure is meant to evaluate hospital quality (or utilization in the case of readmissions), adjusting for SES is appropriate because it is unrealistic to expect a health system to reduce income inequality and provide safe housing. Failure to adjust for SES, which has a large impact on outcomes, may mask a quality of care issue. Conversely, if the purpose of a measure is for a community to improve population health, then it should not be adjusted for SES because the community could adjust for income inequality.

Despite the complex ethical challenges created by the efforts to reduce readmissions, there has been virtually no public dialogue with patients, physicians, and policy makers regarding how to balance the trade-offs between reducing readmission and maintaining safety. Patients would likely value increased survival more than reduced readmissions, yet the current CMS Five-Star Rating System for hospital quality weighs readmissions equally with mortality in its hospital rankings, potentially misinforming patients. For example, many well-known academic medical centers score well (4 or 5 stars) on mortality and poorly (1 or 2 stars) on readmissions, resulting in a low or average overall score, calling into question face validity and confounding consumers struggling to make decisions about where to seek care. The Medicare Payment Advisory Commission’s Report to the Congress¹⁴ highlights the multiple significant systematic and random errors with the hospital readmission data.

Revisiting the Hospital Readmission Measures

Given significant bias in the hospital readmission measures and the ethical challenges imposed by reducing readmissions, potentially at the expense of survival, we believe CMS needs to take action to remedy the problem. First, CMS should drop hospital readmissions as a quality measure from its hospital rankings. Other hospital-rating groups and insurers should do the same. When included in payment schemes, readmissions should not be construed as a quality measure but as a utilization measure, like length of stay.

Second, the Department of Health & Human Services (HHS) should invest in maturing the hospital readmission measures to ensure construct, content, and criterion validity and reliability. No doubt the risk adjustment is complex and may be inherently limited using Medicare claims data. In the case of SES adjustment, for example, limited numbers of SES measures can be constructed from current data sources.^8,13 There are other approaches to address this recommendation. For example, HHS could define a preventable readmission as one linked to some process or outcome of hospital care, such as whether the patient was discharged on an inhaler. The National Quality Forum used this approach to define a preventable venous thromboembolic event as one occurring when a patient did not receive appropriate prophylaxis. In this way, only hospital 1 in the 3 scenarios for the patient with COPD would be penalized. However, we recognize that it is not always simple to define specific process measures (eg, prescribing an inhaler) that link to readmission outcomes and that there may be other important yet hard-to-measure interventions (eg, patient and family education) that are important components of patient-centered care and readmission prevention. This is why readmissions are so challenging as a quality measure. If experts cannot define clinician behaviors that have a strong theory of change or are causally related to reduced readmissions, it is hard to call readmissions a modifiable quality measure. Another potential strategy to level the playing field would be to compare readmission rates across peer institutions only. For instance, tertiary-care safety net hospitals would be compared to one another and rural community hospitals would be compared to one another.¹⁴ Lastly, new data sources could be added to account for the social, community-level, public health, and personal health factors that heavily influence a patient’s risk for readmission, in addition to hospital-level factors. Appropriate methods will be needed to develop statistical models for risk adjustment; however, this is a complex topic and beyond the scope of the current paper.

Third, HHS could continue to use the current readmission measures as population health measures while supporting multistakeholder teams to better understand how people and their communities, public health agencies, insurers, and healthcare providers can collaborate to help patients thrive and avoid readmissions by addressing true defects in care and care coordination.

While it is understandable why policy makers chose to focus on hospital readmissions, and while we recognize that concerns about the measures were unknown when they were created, emerging evidence demonstrates that the current readmission measures (particularly when used as a quality metric) lack construct validity, contain significant bias and systematic errors, and create ethical tension by rewarding hospitals both financially and reputationally for turning away sick and socially disadvantaged patients who may, consequently, have adverse outcomes. Current readmission measures need to be reconsidered.

Acknowledgments

The authors thank Christine G. Holzmueller, BLA, with the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, for her assistance in editing the manuscript and preparing it for journal submission.

Disclosure

Dr. Pronovost errs on the side of full disclosure and reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc. (improve blood pressure control); honoraria from various healthcare organizations for speaking on patient safety and quality (the Leigh Bureau manages engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; and was receiving stock and fees to serve as a director for Cantel Medical up until 24 months ago. Dr. Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. Dr. Brotman, Dr. Hoyer, and Ms. Deutschendorf report no relevant conflicts of interest.

Hospital readmission rates are a consequential and contentious measure of hospital quality. Readmissions within 30 days of hospital discharge are part of the Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing Program and are publicly reported. Hospital-wide readmissions and condition-specific readmissions are heavily weighted by US News & World Report in its hospital rankings and in the new CMS Five-Star Quality Rating System.¹ However, clinicians and researchers question the construct validity of current readmission measures.^2,3

The focus on readmissions began in 2009 when Jencks et al.⁴ reported that 20% of Medicare patients were readmitted within 30 days after hospital discharge. Policy makers embraced readmission reduction, assuming that a hospital readmission so soon after discharge reflected poor quality of hospital care and that, with focused efforts, hospitals could reduce readmissions and save CMS money. In 2010, the Affordable Care Act introduced an initiative to reduce readmissions and, in 2012, the Hospital Readmission Reduction Program was implemented, financially penalizing hospitals with higher-than-expected readmission rates for patients hospitalized with principal diagnoses of heart failure, myocardial infarction, and pneumonia.⁵ Readmission measures have since proliferated and now include pay-for-performance metrics for hospitalizations for chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting, and total hip or knee arthroplasty. Measures are also reported for stroke patients and for “hospital-wide readmissions,” a catch-all measure intended to capture readmission rates across most diagnoses, with various exclusions intended to prevent counting planned readmissions (eg, hospitalization for cholecystectomy following a hospitalization for cholecystitis). These measures use claims data to construct hierarchical regression models at the patient and hospital levels, assuming that variation among readmission rates are due to hospital quality effects. The goal of this approach is to level the playing field to avoid penalizing hospitals for caring for sicker patients who are at higher risk for readmission for reasons unrelated to hospital care. Yet hospital readmissions are influenced by a complex set of variables that go well beyond hospital care, some of which may be better captured by existing models than others. Below we review several potential biases in the hospital readmission measures and offer policy recommendations to improve the accuracy of these measures.

Variation in a quality measure is influenced by the quality of the underlying data, the mix of patients served, bias in the performance measure, and the degree of systemic or random error.⁶ Hospital readmission rates are subject to multiple sources of variation, and true differences in the quality of care are often a much smaller source of this variation. A recent analysis of patient readmissions following general surgery found that the majority were unrelated to suboptimal medical care.⁷ Consider 3 scenarios in which a patient with COPD is readmitted 22 days after discharge. In hospital 1, the patient was discharged without a prescription for a steroid inhaler. In hospital 2, the patient was discharged on a steroid inhaler, filled the prescription, and elected not to use it. In hospital 3, the patient was discharged on a steroid inhaler and was provided medical assistance to fill the prescription but still could not afford the $15 copay. In all 3 scenarios, the hospital would be equally culpable under the current readmission measures, suffering financial and reputational penalties.

Yet the hospitals in these scenarios are not equally culpable. Variation in the mix of patients and bias in the measure impacted performance. Hospital 1 should clearly be held accountable for the readmission. In the cases of hospitals 2 and 3, the situations are more nuanced. More education about COPD, financial investment by the hospital to cover a copay, or a different transitional care approach may have increased the likelihood of patient compliance, but, ultimately, hospitals 2 and 3 were impacted by personal health behaviors and access to public health services and financial assistance, and the readmissions were less within their control.⁸

To be valid, hospital readmission measures would need to ensure that all hospitals are similar in patient characteristics and in the need for an availability of public health services. Yet these factors vary among hospitals and cannot be accounted for by models that rely exclusively on patient-level variables, such as the nature and severity of illness. As a result, the existing readmission measures are biased against certain types of hospitals. Hospitals that treat a greater proportion of patients who are socioeconomically disadvantaged; who lack access to primary care, medical assistance, or public health programs; and who have substance abuse and mental health issues will have higher readmission rates. Hospitals that care for patients who fail initial treatments and require referral for complex care will also have higher readmission rates. These types of patients are not randomly distributed throughout our healthcare system. They are clustered at rural hospitals in underserved areas, certain urban health systems, safety net hospitals, and academic health centers. It is not surprising that readmission penalties have most severely impacted large academic hospitals that care for disadvantaged populations.² These penalties may have unintended consequences, reducing a hospital’s willingness to care for disadvantaged populations.

While these biases may unfairly harm hospitals caring for disadvantaged patients, the readmission measures may also indirectly harm patients. Low hospital readmission rates are not associated with reduced mortality and, in some instances, track with higher mortality.^9-11 This may result from measurement factors (patients who die cannot be readmitted), from neighborhood socioeconomic status (SES) factors that may impact readmissions more,¹² or from actual patient harm (some patients need acute care following discharge and may have worse outcomes if that care is delayed).¹¹ Doctors have long recognized this potential risk; empiric evidence now supports them. While mortality measures may also be impacted by sociodemographic variables,¹³ whether to adjust for SES should be defined by the purpose of the measure. If the measure is meant to evaluate hospital quality (or utilization in the case of readmissions), adjusting for SES is appropriate because it is unrealistic to expect a health system to reduce income inequality and provide safe housing. Failure to adjust for SES, which has a large impact on outcomes, may mask a quality of care issue. Conversely, if the purpose of a measure is for a community to improve population health, then it should not be adjusted for SES because the community could adjust for income inequality.

Despite the complex ethical challenges created by the efforts to reduce readmissions, there has been virtually no public dialogue with patients, physicians, and policy makers regarding how to balance the trade-offs between reducing readmission and maintaining safety. Patients would likely value increased survival more than reduced readmissions, yet the current CMS Five-Star Rating System for hospital quality weighs readmissions equally with mortality in its hospital rankings, potentially misinforming patients. For example, many well-known academic medical centers score well (4 or 5 stars) on mortality and poorly (1 or 2 stars) on readmissions, resulting in a low or average overall score, calling into question face validity and confounding consumers struggling to make decisions about where to seek care. The Medicare Payment Advisory Commission’s Report to the Congress¹⁴ highlights the multiple significant systematic and random errors with the hospital readmission data.

Revisiting the Hospital Readmission Measures

Given significant bias in the hospital readmission measures and the ethical challenges imposed by reducing readmissions, potentially at the expense of survival, we believe CMS needs to take action to remedy the problem. First, CMS should drop hospital readmissions as a quality measure from its hospital rankings. Other hospital-rating groups and insurers should do the same. When included in payment schemes, readmissions should not be construed as a quality measure but as a utilization measure, like length of stay.

Second, the Department of Health & Human Services (HHS) should invest in maturing the hospital readmission measures to ensure construct, content, and criterion validity and reliability. No doubt the risk adjustment is complex and may be inherently limited using Medicare claims data. In the case of SES adjustment, for example, limited numbers of SES measures can be constructed from current data sources.^8,13 There are other approaches to address this recommendation. For example, HHS could define a preventable readmission as one linked to some process or outcome of hospital care, such as whether the patient was discharged on an inhaler. The National Quality Forum used this approach to define a preventable venous thromboembolic event as one occurring when a patient did not receive appropriate prophylaxis. In this way, only hospital 1 in the 3 scenarios for the patient with COPD would be penalized. However, we recognize that it is not always simple to define specific process measures (eg, prescribing an inhaler) that link to readmission outcomes and that there may be other important yet hard-to-measure interventions (eg, patient and family education) that are important components of patient-centered care and readmission prevention. This is why readmissions are so challenging as a quality measure. If experts cannot define clinician behaviors that have a strong theory of change or are causally related to reduced readmissions, it is hard to call readmissions a modifiable quality measure. Another potential strategy to level the playing field would be to compare readmission rates across peer institutions only. For instance, tertiary-care safety net hospitals would be compared to one another and rural community hospitals would be compared to one another.¹⁴ Lastly, new data sources could be added to account for the social, community-level, public health, and personal health factors that heavily influence a patient’s risk for readmission, in addition to hospital-level factors. Appropriate methods will be needed to develop statistical models for risk adjustment; however, this is a complex topic and beyond the scope of the current paper.

Third, HHS could continue to use the current readmission measures as population health measures while supporting multistakeholder teams to better understand how people and their communities, public health agencies, insurers, and healthcare providers can collaborate to help patients thrive and avoid readmissions by addressing true defects in care and care coordination.

While it is understandable why policy makers chose to focus on hospital readmissions, and while we recognize that concerns about the measures were unknown when they were created, emerging evidence demonstrates that the current readmission measures (particularly when used as a quality metric) lack construct validity, contain significant bias and systematic errors, and create ethical tension by rewarding hospitals both financially and reputationally for turning away sick and socially disadvantaged patients who may, consequently, have adverse outcomes. Current readmission measures need to be reconsidered.

Acknowledgments

The authors thank Christine G. Holzmueller, BLA, with the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, for her assistance in editing the manuscript and preparing it for journal submission.

Disclosure

Dr. Pronovost errs on the side of full disclosure and reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc. (improve blood pressure control); honoraria from various healthcare organizations for speaking on patient safety and quality (the Leigh Bureau manages engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; and was receiving stock and fees to serve as a director for Cantel Medical up until 24 months ago. Dr. Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. Dr. Brotman, Dr. Hoyer, and Ms. Deutschendorf report no relevant conflicts of interest.

Hospital readmission rates are a consequential and contentious measure of hospital quality. Readmissions within 30 days of hospital discharge are part of the Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing Program and are publicly reported. Hospital-wide readmissions and condition-specific readmissions are heavily weighted by US News & World Report in its hospital rankings and in the new CMS Five-Star Quality Rating System.¹ However, clinicians and researchers question the construct validity of current readmission measures.^2,3

The focus on readmissions began in 2009 when Jencks et al.⁴ reported that 20% of Medicare patients were readmitted within 30 days after hospital discharge. Policy makers embraced readmission reduction, assuming that a hospital readmission so soon after discharge reflected poor quality of hospital care and that, with focused efforts, hospitals could reduce readmissions and save CMS money. In 2010, the Affordable Care Act introduced an initiative to reduce readmissions and, in 2012, the Hospital Readmission Reduction Program was implemented, financially penalizing hospitals with higher-than-expected readmission rates for patients hospitalized with principal diagnoses of heart failure, myocardial infarction, and pneumonia.⁵ Readmission measures have since proliferated and now include pay-for-performance metrics for hospitalizations for chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting, and total hip or knee arthroplasty. Measures are also reported for stroke patients and for “hospital-wide readmissions,” a catch-all measure intended to capture readmission rates across most diagnoses, with various exclusions intended to prevent counting planned readmissions (eg, hospitalization for cholecystectomy following a hospitalization for cholecystitis). These measures use claims data to construct hierarchical regression models at the patient and hospital levels, assuming that variation among readmission rates are due to hospital quality effects. The goal of this approach is to level the playing field to avoid penalizing hospitals for caring for sicker patients who are at higher risk for readmission for reasons unrelated to hospital care. Yet hospital readmissions are influenced by a complex set of variables that go well beyond hospital care, some of which may be better captured by existing models than others. Below we review several potential biases in the hospital readmission measures and offer policy recommendations to improve the accuracy of these measures.

Variation in a quality measure is influenced by the quality of the underlying data, the mix of patients served, bias in the performance measure, and the degree of systemic or random error.⁶ Hospital readmission rates are subject to multiple sources of variation, and true differences in the quality of care are often a much smaller source of this variation. A recent analysis of patient readmissions following general surgery found that the majority were unrelated to suboptimal medical care.⁷ Consider 3 scenarios in which a patient with COPD is readmitted 22 days after discharge. In hospital 1, the patient was discharged without a prescription for a steroid inhaler. In hospital 2, the patient was discharged on a steroid inhaler, filled the prescription, and elected not to use it. In hospital 3, the patient was discharged on a steroid inhaler and was provided medical assistance to fill the prescription but still could not afford the $15 copay. In all 3 scenarios, the hospital would be equally culpable under the current readmission measures, suffering financial and reputational penalties.

Yet the hospitals in these scenarios are not equally culpable. Variation in the mix of patients and bias in the measure impacted performance. Hospital 1 should clearly be held accountable for the readmission. In the cases of hospitals 2 and 3, the situations are more nuanced. More education about COPD, financial investment by the hospital to cover a copay, or a different transitional care approach may have increased the likelihood of patient compliance, but, ultimately, hospitals 2 and 3 were impacted by personal health behaviors and access to public health services and financial assistance, and the readmissions were less within their control.⁸

To be valid, hospital readmission measures would need to ensure that all hospitals are similar in patient characteristics and in the need for an availability of public health services. Yet these factors vary among hospitals and cannot be accounted for by models that rely exclusively on patient-level variables, such as the nature and severity of illness. As a result, the existing readmission measures are biased against certain types of hospitals. Hospitals that treat a greater proportion of patients who are socioeconomically disadvantaged; who lack access to primary care, medical assistance, or public health programs; and who have substance abuse and mental health issues will have higher readmission rates. Hospitals that care for patients who fail initial treatments and require referral for complex care will also have higher readmission rates. These types of patients are not randomly distributed throughout our healthcare system. They are clustered at rural hospitals in underserved areas, certain urban health systems, safety net hospitals, and academic health centers. It is not surprising that readmission penalties have most severely impacted large academic hospitals that care for disadvantaged populations.² These penalties may have unintended consequences, reducing a hospital’s willingness to care for disadvantaged populations.

While these biases may unfairly harm hospitals caring for disadvantaged patients, the readmission measures may also indirectly harm patients. Low hospital readmission rates are not associated with reduced mortality and, in some instances, track with higher mortality.^9-11 This may result from measurement factors (patients who die cannot be readmitted), from neighborhood socioeconomic status (SES) factors that may impact readmissions more,¹² or from actual patient harm (some patients need acute care following discharge and may have worse outcomes if that care is delayed).¹¹ Doctors have long recognized this potential risk; empiric evidence now supports them. While mortality measures may also be impacted by sociodemographic variables,¹³ whether to adjust for SES should be defined by the purpose of the measure. If the measure is meant to evaluate hospital quality (or utilization in the case of readmissions), adjusting for SES is appropriate because it is unrealistic to expect a health system to reduce income inequality and provide safe housing. Failure to adjust for SES, which has a large impact on outcomes, may mask a quality of care issue. Conversely, if the purpose of a measure is for a community to improve population health, then it should not be adjusted for SES because the community could adjust for income inequality.

Despite the complex ethical challenges created by the efforts to reduce readmissions, there has been virtually no public dialogue with patients, physicians, and policy makers regarding how to balance the trade-offs between reducing readmission and maintaining safety. Patients would likely value increased survival more than reduced readmissions, yet the current CMS Five-Star Rating System for hospital quality weighs readmissions equally with mortality in its hospital rankings, potentially misinforming patients. For example, many well-known academic medical centers score well (4 or 5 stars) on mortality and poorly (1 or 2 stars) on readmissions, resulting in a low or average overall score, calling into question face validity and confounding consumers struggling to make decisions about where to seek care. The Medicare Payment Advisory Commission’s Report to the Congress¹⁴ highlights the multiple significant systematic and random errors with the hospital readmission data.

Revisiting the Hospital Readmission Measures

Given significant bias in the hospital readmission measures and the ethical challenges imposed by reducing readmissions, potentially at the expense of survival, we believe CMS needs to take action to remedy the problem. First, CMS should drop hospital readmissions as a quality measure from its hospital rankings. Other hospital-rating groups and insurers should do the same. When included in payment schemes, readmissions should not be construed as a quality measure but as a utilization measure, like length of stay.

Second, the Department of Health & Human Services (HHS) should invest in maturing the hospital readmission measures to ensure construct, content, and criterion validity and reliability. No doubt the risk adjustment is complex and may be inherently limited using Medicare claims data. In the case of SES adjustment, for example, limited numbers of SES measures can be constructed from current data sources.^8,13 There are other approaches to address this recommendation. For example, HHS could define a preventable readmission as one linked to some process or outcome of hospital care, such as whether the patient was discharged on an inhaler. The National Quality Forum used this approach to define a preventable venous thromboembolic event as one occurring when a patient did not receive appropriate prophylaxis. In this way, only hospital 1 in the 3 scenarios for the patient with COPD would be penalized. However, we recognize that it is not always simple to define specific process measures (eg, prescribing an inhaler) that link to readmission outcomes and that there may be other important yet hard-to-measure interventions (eg, patient and family education) that are important components of patient-centered care and readmission prevention. This is why readmissions are so challenging as a quality measure. If experts cannot define clinician behaviors that have a strong theory of change or are causally related to reduced readmissions, it is hard to call readmissions a modifiable quality measure. Another potential strategy to level the playing field would be to compare readmission rates across peer institutions only. For instance, tertiary-care safety net hospitals would be compared to one another and rural community hospitals would be compared to one another.¹⁴ Lastly, new data sources could be added to account for the social, community-level, public health, and personal health factors that heavily influence a patient’s risk for readmission, in addition to hospital-level factors. Appropriate methods will be needed to develop statistical models for risk adjustment; however, this is a complex topic and beyond the scope of the current paper.

Third, HHS could continue to use the current readmission measures as population health measures while supporting multistakeholder teams to better understand how people and their communities, public health agencies, insurers, and healthcare providers can collaborate to help patients thrive and avoid readmissions by addressing true defects in care and care coordination.

While it is understandable why policy makers chose to focus on hospital readmissions, and while we recognize that concerns about the measures were unknown when they were created, emerging evidence demonstrates that the current readmission measures (particularly when used as a quality metric) lack construct validity, contain significant bias and systematic errors, and create ethical tension by rewarding hospitals both financially and reputationally for turning away sick and socially disadvantaged patients who may, consequently, have adverse outcomes. Current readmission measures need to be reconsidered.

Acknowledgments

The authors thank Christine G. Holzmueller, BLA, with the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, for her assistance in editing the manuscript and preparing it for journal submission.

Disclosure

Dr. Pronovost errs on the side of full disclosure and reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association Inc. (improve blood pressure control); honoraria from various healthcare organizations for speaking on patient safety and quality (the Leigh Bureau manages engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; and was receiving stock and fees to serve as a director for Cantel Medical up until 24 months ago. Dr. Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. Dr. Brotman, Dr. Hoyer, and Ms. Deutschendorf report no relevant conflicts of interest.

The United States is facing an epidemic of prescription opioid and heroin use, which has been linked to the escalating prescribing of opioid analgesics. Though opioid prescriptions appear to be reaching a plateau, estimates suggest there are at least 900,000 active heroin users in the United States, and this number continues to grow.¹ One response to this epidemic (through state legislation and medical society guidelines) has been a move to reduce opioid prescribing in order to diminish the potential for diversion and misuse.² However, the treatment of pain is not the sole driver of heroin epidemiology, and new strategies are also needed to better engage patients with existing opioid use disorders (OUDs) to begin treatment. These patients are increasingly hospitalized for infectious comorbidities of injection drug use, trauma, or pregnancy, and this may present a unique opportunity to initiate these patients on maintenance opioid agonist therapy, the most effective option for medication-assisted treatment (MAT) for addiction.

Patients with OUDs comprise an estimated 2% to 4% of hospitalized patients, representing a disproportionately large number of inpatients.^3-6 According to a recent analysis of data from the National (Nationwide) Inpatient Sample, the estimated annual number of hospitalizations associated with OUDs in the United States increased from approximately 300,000 to more than 500,000 in the decade from 2002 to 2012.⁷ Severe bacterial infections associated with intravenous administration of opioids (including endocarditis, osteomyelitis, septic arthritis, and epidural abscess) increased substantially at an estimated cost of more than $700 million in 2012.⁷ Over a similar period, the prevalence of opioid use among women in labor increased from 13.7 to 22.0 per 10,000 live births,⁸ and there was a corresponding rise in admissions to neonatal intensive care units for neonatal abstinence syndrome.⁹ As the prevalence of prescription drug and heroin dependence continues to rise across the United States, hospitals and clinicians find themselves on the front lines of this epidemic, creating potential opportunities to engage patients in recovery, a “treatable moment” for this vulnerable population.¹⁰

Currently, a common approach in the hospitalized patient is to attempt medically assisted withdrawal using a rapid taper of long-acting opioids. This process may appeal to healthcare providers who hope to guide their patients in transitioning to opioid abstinence. However, tapering an opioid regimen, even over a period of months, results in unacceptably high rates of relapse (as high as 70% to 90% in some studies), especially when a patient is acutely ill and symptomatic from a concurrent medical issue.^11-13 In the hospital setting, this treatment failure can manifest as pain and undertreated withdrawal symptoms (such as agitation, arthralgias, and gastrointestinal distress), which may hinder some patients from completing their treatment or drive some to leave against medical advice.¹⁴ Further harm may occur when an inpatient rapid taper is accomplished, putting patients at increased risk of a fatal relapse after discharge due to loss of tolerance.¹⁵Maintenance opioid agonist therapy with buprenorphine or methadone, in which a long-acting opioid is titrated until craving and withdrawal symptoms are well controlled, is the first-line modality for MAT among patients with OUDs in outpatient settings and is associated with reduced risk of fatal overdose and all-cause mortality.¹⁶ Initiation and dose stabilization of agonist therapy with these agents during acute medical hospitalization has been shown to be feasible in a variety of inpatient settings.^17-20 In one trial, patients randomized to buprenorphine induction and linkage to office-based therapy during their inpatient stay were more than 5 times as likely to enter and remain in treatment after discharge when compared with those in whom buprenorphine was tapered.²⁰ International guidelines support the use of maintenance agonist therapy in this context, but this remains an underutilized strategy in recent efforts to treat OUDs in the United States.^21,22 A few key barriers currently prevent this strategy from being applied broadly within our healthcare system.

First, there is a common misconception that regulations prohibit the use of methadone and buprenorphine for opioid agonist therapy by inpatient medical providers without special certification. Title 42 of the Code of Federal Regulations (CFR) provides extensive guidance regarding the use of opioid medications by registered outpatient opioid treatment programs. However, it also contains an exemption from these rules for hospitals treating patients with emergent medical needs (21 CFR § 1306.07[c]) allowing hospital-based clinicians “to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction” without restriction. According to guidelines from the Substance Abuse and Mental Health Services Administration, this exemption applies to the use of both methadone and buprenorphine.²³

Many clinicians and hospital pharmacy departments interpret this law to limit the use of maintenance therapy in patients already enrolled in outpatient programs or to require a rapid taper over the first 3 days of hospitalization. However, these interpretations may in part be rooted in confusion with an adjacent section of the regulations (21 CFR § 1306.07[b]) directed at outpatient physicians providing time-limited, emergency treatment for withdrawal in an office setting. The application of this time limit to hospitalized patients has not been supported by communication from the Drug Enforcement Agency.²⁴ There is no case law or other regulation requiring an opioid regimen to be time limited for patients during medical hospitalization, and hospital policies need not place undue constraints on the ability of clinicians to stabilize patients on maintenance therapy and transition them to outpatient treatment.

Second, the limited capacity of existing opioid maintenance programs can lead to a gap in treatment upon hospital discharge for patients in whom methadone or buprenorphine is initiated. Health delivery systems can play a role in mitigating the impact of this resource gap. Integrating the model of screening, brief intervention, and referral to treatment into hospital admission processes and engaging social workers, addiction consult services (where available), and other supports early in the course of hospitalization can help facilitate appropriate follow-up care.^25,26 Hospitals may also be eligible for federal funding to strengthen local referral networks for outpatient MAT programs under Section 103 of the Comprehensive Addiction and Recovery Act passed into law in July 2016. Innovative delivery models designed to enhance integration across community stakeholders in healthcare, social services, and criminal justice have recently been developed, such as Vermont’s “Hub and Spoke” model,²⁷ Boston Medical Center’s Faster Paths opioid urgent care center,²⁸ and the police-led Angel Program in Gloucester, Massachusetts.²⁹ Implementation science studies will be needed to identify the most effective ways to engage inpatient medical teams in such efforts.

Currently, individual providers can already play a central role in providing a bridge for patients in whom a delay in beginning MAT cannot be avoided upon discharge. Interim buprenorphine maintenance treatment has been shown to dramatically decrease the use of illicit opioids among those awaiting initiation of comprehensive MAT programs and substantially increase retention in long-term treatment.^20,30,31 With the recent expansion of the limits on buprenorphine prescriptions to 275 patients per provider (part of the waiver required under the Drug Addiction Treatment Act [DATA] of 2000 to provide outpatient buprenorphine treatment, also known as a DATA waiver), this may be an increasingly promising option for hospital discharge.

Obtaining a waiver to prescribe buprenorphine is not required for the inpatient initiation of buprenorphine therapy. However, doing so is relatively simple (requiring an online, 8-hour training [https://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training]) and allows hospital-based providers not only to ensure optimal management of OUDs during hospitalization but also to help their patients with the next steps toward recovery after discharge. The use of buprenorphine may be challenging in some patients with significant pain as a component of their medical condition. For these patients, methadone will likely be better tolerated.

Additional funding is also urgently needed to expand the capacity of existing opioid treatment programs and create specialized discharge-transition clinics that can provide structured interim opioid therapy while patients are on waitlists for traditional MAT programs. Requiring patients who are not ready or able to begin long-term maintenance agonist therapy to rapidly taper an inpatient opioid regimen unnecessarily puts them at risk for overdose after discharge.¹⁵ Regardless of the available resources for long-term treatment within the community, hospital discharge planning should include a naloxone prescription and brief training for patients and their loved ones.³² The long-acting opioid antagonist, depot naltrexone, is another effective, alternative MAT option and is increasingly used in community settings among patients who are motivated to achieve opioid abstinence.^33,34 It has not yet been studied among hospitalized patients, and further research is needed to determine if it could be a viable option for discharge. However, the requirement that a patient be abstinent from opioids for 7 to 10 days prior to administering the first dose of depot naltrexone may serve as a significant barrier to its use for most hospitalized patients.

Finally, healthcare providers must be trained in the appropriate use of opioid agonist therapy. Medical schools, residency programs, and schools of pharmacy and nursing should develop curricula to expand the capacity of nonspecialists to care for patients with OUDs and to focus on judicious analgesic prescribing to prevent chronic opioid use. This curriculum should address the appropriate titration of methadone and buprenorphine for agonist therapy and address the stigma faced by patients with substance use disorders. Other important topics include the management of overdose and withdrawal symptoms, structured approaches to pain management in patients with OUDs, harm-reduction methods, and multidisciplinary care for the psychosocial and psychiatric comorbidities of addiction. Though international guidelines have been developed for the inpatient management of patients with OUDs,^21,22 hospitals and professional societies should take a leadership role in facilitating continuing education to disseminate them among current medical providers.

There is great potential for the leadership and front-line staff of hospital systems, with a few key changes in policy and practice, to become advocates for patients with OUDs to access treatment. As perspectives about opioid prescribing change amid efforts to limit the escalation of the current heroin epidemic, it is vital to identify opportunities to reduce opioid exposure for opioid-naïve patients and enhance the engagement of patients diagnosed with OUDs in treatment.

Disclosure

 The authors have no conflicts of interest to declare.

The United States is facing an epidemic of prescription opioid and heroin use, which has been linked to the escalating prescribing of opioid analgesics. Though opioid prescriptions appear to be reaching a plateau, estimates suggest there are at least 900,000 active heroin users in the United States, and this number continues to grow.¹ One response to this epidemic (through state legislation and medical society guidelines) has been a move to reduce opioid prescribing in order to diminish the potential for diversion and misuse.² However, the treatment of pain is not the sole driver of heroin epidemiology, and new strategies are also needed to better engage patients with existing opioid use disorders (OUDs) to begin treatment. These patients are increasingly hospitalized for infectious comorbidities of injection drug use, trauma, or pregnancy, and this may present a unique opportunity to initiate these patients on maintenance opioid agonist therapy, the most effective option for medication-assisted treatment (MAT) for addiction.

Patients with OUDs comprise an estimated 2% to 4% of hospitalized patients, representing a disproportionately large number of inpatients.^3-6 According to a recent analysis of data from the National (Nationwide) Inpatient Sample, the estimated annual number of hospitalizations associated with OUDs in the United States increased from approximately 300,000 to more than 500,000 in the decade from 2002 to 2012.⁷ Severe bacterial infections associated with intravenous administration of opioids (including endocarditis, osteomyelitis, septic arthritis, and epidural abscess) increased substantially at an estimated cost of more than $700 million in 2012.⁷ Over a similar period, the prevalence of opioid use among women in labor increased from 13.7 to 22.0 per 10,000 live births,⁸ and there was a corresponding rise in admissions to neonatal intensive care units for neonatal abstinence syndrome.⁹ As the prevalence of prescription drug and heroin dependence continues to rise across the United States, hospitals and clinicians find themselves on the front lines of this epidemic, creating potential opportunities to engage patients in recovery, a “treatable moment” for this vulnerable population.¹⁰

Currently, a common approach in the hospitalized patient is to attempt medically assisted withdrawal using a rapid taper of long-acting opioids. This process may appeal to healthcare providers who hope to guide their patients in transitioning to opioid abstinence. However, tapering an opioid regimen, even over a period of months, results in unacceptably high rates of relapse (as high as 70% to 90% in some studies), especially when a patient is acutely ill and symptomatic from a concurrent medical issue.^11-13 In the hospital setting, this treatment failure can manifest as pain and undertreated withdrawal symptoms (such as agitation, arthralgias, and gastrointestinal distress), which may hinder some patients from completing their treatment or drive some to leave against medical advice.¹⁴ Further harm may occur when an inpatient rapid taper is accomplished, putting patients at increased risk of a fatal relapse after discharge due to loss of tolerance.¹⁵Maintenance opioid agonist therapy with buprenorphine or methadone, in which a long-acting opioid is titrated until craving and withdrawal symptoms are well controlled, is the first-line modality for MAT among patients with OUDs in outpatient settings and is associated with reduced risk of fatal overdose and all-cause mortality.¹⁶ Initiation and dose stabilization of agonist therapy with these agents during acute medical hospitalization has been shown to be feasible in a variety of inpatient settings.^17-20 In one trial, patients randomized to buprenorphine induction and linkage to office-based therapy during their inpatient stay were more than 5 times as likely to enter and remain in treatment after discharge when compared with those in whom buprenorphine was tapered.²⁰ International guidelines support the use of maintenance agonist therapy in this context, but this remains an underutilized strategy in recent efforts to treat OUDs in the United States.^21,22 A few key barriers currently prevent this strategy from being applied broadly within our healthcare system.

First, there is a common misconception that regulations prohibit the use of methadone and buprenorphine for opioid agonist therapy by inpatient medical providers without special certification. Title 42 of the Code of Federal Regulations (CFR) provides extensive guidance regarding the use of opioid medications by registered outpatient opioid treatment programs. However, it also contains an exemption from these rules for hospitals treating patients with emergent medical needs (21 CFR § 1306.07[c]) allowing hospital-based clinicians “to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction” without restriction. According to guidelines from the Substance Abuse and Mental Health Services Administration, this exemption applies to the use of both methadone and buprenorphine.²³

Many clinicians and hospital pharmacy departments interpret this law to limit the use of maintenance therapy in patients already enrolled in outpatient programs or to require a rapid taper over the first 3 days of hospitalization. However, these interpretations may in part be rooted in confusion with an adjacent section of the regulations (21 CFR § 1306.07[b]) directed at outpatient physicians providing time-limited, emergency treatment for withdrawal in an office setting. The application of this time limit to hospitalized patients has not been supported by communication from the Drug Enforcement Agency.²⁴ There is no case law or other regulation requiring an opioid regimen to be time limited for patients during medical hospitalization, and hospital policies need not place undue constraints on the ability of clinicians to stabilize patients on maintenance therapy and transition them to outpatient treatment.

Second, the limited capacity of existing opioid maintenance programs can lead to a gap in treatment upon hospital discharge for patients in whom methadone or buprenorphine is initiated. Health delivery systems can play a role in mitigating the impact of this resource gap. Integrating the model of screening, brief intervention, and referral to treatment into hospital admission processes and engaging social workers, addiction consult services (where available), and other supports early in the course of hospitalization can help facilitate appropriate follow-up care.^25,26 Hospitals may also be eligible for federal funding to strengthen local referral networks for outpatient MAT programs under Section 103 of the Comprehensive Addiction and Recovery Act passed into law in July 2016. Innovative delivery models designed to enhance integration across community stakeholders in healthcare, social services, and criminal justice have recently been developed, such as Vermont’s “Hub and Spoke” model,²⁷ Boston Medical Center’s Faster Paths opioid urgent care center,²⁸ and the police-led Angel Program in Gloucester, Massachusetts.²⁹ Implementation science studies will be needed to identify the most effective ways to engage inpatient medical teams in such efforts.

Currently, individual providers can already play a central role in providing a bridge for patients in whom a delay in beginning MAT cannot be avoided upon discharge. Interim buprenorphine maintenance treatment has been shown to dramatically decrease the use of illicit opioids among those awaiting initiation of comprehensive MAT programs and substantially increase retention in long-term treatment.^20,30,31 With the recent expansion of the limits on buprenorphine prescriptions to 275 patients per provider (part of the waiver required under the Drug Addiction Treatment Act [DATA] of 2000 to provide outpatient buprenorphine treatment, also known as a DATA waiver), this may be an increasingly promising option for hospital discharge.

Obtaining a waiver to prescribe buprenorphine is not required for the inpatient initiation of buprenorphine therapy. However, doing so is relatively simple (requiring an online, 8-hour training [https://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training]) and allows hospital-based providers not only to ensure optimal management of OUDs during hospitalization but also to help their patients with the next steps toward recovery after discharge. The use of buprenorphine may be challenging in some patients with significant pain as a component of their medical condition. For these patients, methadone will likely be better tolerated.

Additional funding is also urgently needed to expand the capacity of existing opioid treatment programs and create specialized discharge-transition clinics that can provide structured interim opioid therapy while patients are on waitlists for traditional MAT programs. Requiring patients who are not ready or able to begin long-term maintenance agonist therapy to rapidly taper an inpatient opioid regimen unnecessarily puts them at risk for overdose after discharge.¹⁵ Regardless of the available resources for long-term treatment within the community, hospital discharge planning should include a naloxone prescription and brief training for patients and their loved ones.³² The long-acting opioid antagonist, depot naltrexone, is another effective, alternative MAT option and is increasingly used in community settings among patients who are motivated to achieve opioid abstinence.^33,34 It has not yet been studied among hospitalized patients, and further research is needed to determine if it could be a viable option for discharge. However, the requirement that a patient be abstinent from opioids for 7 to 10 days prior to administering the first dose of depot naltrexone may serve as a significant barrier to its use for most hospitalized patients.

Finally, healthcare providers must be trained in the appropriate use of opioid agonist therapy. Medical schools, residency programs, and schools of pharmacy and nursing should develop curricula to expand the capacity of nonspecialists to care for patients with OUDs and to focus on judicious analgesic prescribing to prevent chronic opioid use. This curriculum should address the appropriate titration of methadone and buprenorphine for agonist therapy and address the stigma faced by patients with substance use disorders. Other important topics include the management of overdose and withdrawal symptoms, structured approaches to pain management in patients with OUDs, harm-reduction methods, and multidisciplinary care for the psychosocial and psychiatric comorbidities of addiction. Though international guidelines have been developed for the inpatient management of patients with OUDs,^21,22 hospitals and professional societies should take a leadership role in facilitating continuing education to disseminate them among current medical providers.

There is great potential for the leadership and front-line staff of hospital systems, with a few key changes in policy and practice, to become advocates for patients with OUDs to access treatment. As perspectives about opioid prescribing change amid efforts to limit the escalation of the current heroin epidemic, it is vital to identify opportunities to reduce opioid exposure for opioid-naïve patients and enhance the engagement of patients diagnosed with OUDs in treatment.

Disclosure

 The authors have no conflicts of interest to declare.

The United States is facing an epidemic of prescription opioid and heroin use, which has been linked to the escalating prescribing of opioid analgesics. Though opioid prescriptions appear to be reaching a plateau, estimates suggest there are at least 900,000 active heroin users in the United States, and this number continues to grow.¹ One response to this epidemic (through state legislation and medical society guidelines) has been a move to reduce opioid prescribing in order to diminish the potential for diversion and misuse.² However, the treatment of pain is not the sole driver of heroin epidemiology, and new strategies are also needed to better engage patients with existing opioid use disorders (OUDs) to begin treatment. These patients are increasingly hospitalized for infectious comorbidities of injection drug use, trauma, or pregnancy, and this may present a unique opportunity to initiate these patients on maintenance opioid agonist therapy, the most effective option for medication-assisted treatment (MAT) for addiction.

Patients with OUDs comprise an estimated 2% to 4% of hospitalized patients, representing a disproportionately large number of inpatients.^3-6 According to a recent analysis of data from the National (Nationwide) Inpatient Sample, the estimated annual number of hospitalizations associated with OUDs in the United States increased from approximately 300,000 to more than 500,000 in the decade from 2002 to 2012.⁷ Severe bacterial infections associated with intravenous administration of opioids (including endocarditis, osteomyelitis, septic arthritis, and epidural abscess) increased substantially at an estimated cost of more than $700 million in 2012.⁷ Over a similar period, the prevalence of opioid use among women in labor increased from 13.7 to 22.0 per 10,000 live births,⁸ and there was a corresponding rise in admissions to neonatal intensive care units for neonatal abstinence syndrome.⁹ As the prevalence of prescription drug and heroin dependence continues to rise across the United States, hospitals and clinicians find themselves on the front lines of this epidemic, creating potential opportunities to engage patients in recovery, a “treatable moment” for this vulnerable population.¹⁰

Currently, a common approach in the hospitalized patient is to attempt medically assisted withdrawal using a rapid taper of long-acting opioids. This process may appeal to healthcare providers who hope to guide their patients in transitioning to opioid abstinence. However, tapering an opioid regimen, even over a period of months, results in unacceptably high rates of relapse (as high as 70% to 90% in some studies), especially when a patient is acutely ill and symptomatic from a concurrent medical issue.^11-13 In the hospital setting, this treatment failure can manifest as pain and undertreated withdrawal symptoms (such as agitation, arthralgias, and gastrointestinal distress), which may hinder some patients from completing their treatment or drive some to leave against medical advice.¹⁴ Further harm may occur when an inpatient rapid taper is accomplished, putting patients at increased risk of a fatal relapse after discharge due to loss of tolerance.¹⁵Maintenance opioid agonist therapy with buprenorphine or methadone, in which a long-acting opioid is titrated until craving and withdrawal symptoms are well controlled, is the first-line modality for MAT among patients with OUDs in outpatient settings and is associated with reduced risk of fatal overdose and all-cause mortality.¹⁶ Initiation and dose stabilization of agonist therapy with these agents during acute medical hospitalization has been shown to be feasible in a variety of inpatient settings.^17-20 In one trial, patients randomized to buprenorphine induction and linkage to office-based therapy during their inpatient stay were more than 5 times as likely to enter and remain in treatment after discharge when compared with those in whom buprenorphine was tapered.²⁰ International guidelines support the use of maintenance agonist therapy in this context, but this remains an underutilized strategy in recent efforts to treat OUDs in the United States.^21,22 A few key barriers currently prevent this strategy from being applied broadly within our healthcare system.

First, there is a common misconception that regulations prohibit the use of methadone and buprenorphine for opioid agonist therapy by inpatient medical providers without special certification. Title 42 of the Code of Federal Regulations (CFR) provides extensive guidance regarding the use of opioid medications by registered outpatient opioid treatment programs. However, it also contains an exemption from these rules for hospitals treating patients with emergent medical needs (21 CFR § 1306.07[c]) allowing hospital-based clinicians “to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction” without restriction. According to guidelines from the Substance Abuse and Mental Health Services Administration, this exemption applies to the use of both methadone and buprenorphine.²³

Many clinicians and hospital pharmacy departments interpret this law to limit the use of maintenance therapy in patients already enrolled in outpatient programs or to require a rapid taper over the first 3 days of hospitalization. However, these interpretations may in part be rooted in confusion with an adjacent section of the regulations (21 CFR § 1306.07[b]) directed at outpatient physicians providing time-limited, emergency treatment for withdrawal in an office setting. The application of this time limit to hospitalized patients has not been supported by communication from the Drug Enforcement Agency.²⁴ There is no case law or other regulation requiring an opioid regimen to be time limited for patients during medical hospitalization, and hospital policies need not place undue constraints on the ability of clinicians to stabilize patients on maintenance therapy and transition them to outpatient treatment.

Second, the limited capacity of existing opioid maintenance programs can lead to a gap in treatment upon hospital discharge for patients in whom methadone or buprenorphine is initiated. Health delivery systems can play a role in mitigating the impact of this resource gap. Integrating the model of screening, brief intervention, and referral to treatment into hospital admission processes and engaging social workers, addiction consult services (where available), and other supports early in the course of hospitalization can help facilitate appropriate follow-up care.^25,26 Hospitals may also be eligible for federal funding to strengthen local referral networks for outpatient MAT programs under Section 103 of the Comprehensive Addiction and Recovery Act passed into law in July 2016. Innovative delivery models designed to enhance integration across community stakeholders in healthcare, social services, and criminal justice have recently been developed, such as Vermont’s “Hub and Spoke” model,²⁷ Boston Medical Center’s Faster Paths opioid urgent care center,²⁸ and the police-led Angel Program in Gloucester, Massachusetts.²⁹ Implementation science studies will be needed to identify the most effective ways to engage inpatient medical teams in such efforts.

Currently, individual providers can already play a central role in providing a bridge for patients in whom a delay in beginning MAT cannot be avoided upon discharge. Interim buprenorphine maintenance treatment has been shown to dramatically decrease the use of illicit opioids among those awaiting initiation of comprehensive MAT programs and substantially increase retention in long-term treatment.^20,30,31 With the recent expansion of the limits on buprenorphine prescriptions to 275 patients per provider (part of the waiver required under the Drug Addiction Treatment Act [DATA] of 2000 to provide outpatient buprenorphine treatment, also known as a DATA waiver), this may be an increasingly promising option for hospital discharge.

Obtaining a waiver to prescribe buprenorphine is not required for the inpatient initiation of buprenorphine therapy. However, doing so is relatively simple (requiring an online, 8-hour training [https://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training]) and allows hospital-based providers not only to ensure optimal management of OUDs during hospitalization but also to help their patients with the next steps toward recovery after discharge. The use of buprenorphine may be challenging in some patients with significant pain as a component of their medical condition. For these patients, methadone will likely be better tolerated.

Additional funding is also urgently needed to expand the capacity of existing opioid treatment programs and create specialized discharge-transition clinics that can provide structured interim opioid therapy while patients are on waitlists for traditional MAT programs. Requiring patients who are not ready or able to begin long-term maintenance agonist therapy to rapidly taper an inpatient opioid regimen unnecessarily puts them at risk for overdose after discharge.¹⁵ Regardless of the available resources for long-term treatment within the community, hospital discharge planning should include a naloxone prescription and brief training for patients and their loved ones.³² The long-acting opioid antagonist, depot naltrexone, is another effective, alternative MAT option and is increasingly used in community settings among patients who are motivated to achieve opioid abstinence.^33,34 It has not yet been studied among hospitalized patients, and further research is needed to determine if it could be a viable option for discharge. However, the requirement that a patient be abstinent from opioids for 7 to 10 days prior to administering the first dose of depot naltrexone may serve as a significant barrier to its use for most hospitalized patients.

Finally, healthcare providers must be trained in the appropriate use of opioid agonist therapy. Medical schools, residency programs, and schools of pharmacy and nursing should develop curricula to expand the capacity of nonspecialists to care for patients with OUDs and to focus on judicious analgesic prescribing to prevent chronic opioid use. This curriculum should address the appropriate titration of methadone and buprenorphine for agonist therapy and address the stigma faced by patients with substance use disorders. Other important topics include the management of overdose and withdrawal symptoms, structured approaches to pain management in patients with OUDs, harm-reduction methods, and multidisciplinary care for the psychosocial and psychiatric comorbidities of addiction. Though international guidelines have been developed for the inpatient management of patients with OUDs,^21,22 hospitals and professional societies should take a leadership role in facilitating continuing education to disseminate them among current medical providers.

There is great potential for the leadership and front-line staff of hospital systems, with a few key changes in policy and practice, to become advocates for patients with OUDs to access treatment. As perspectives about opioid prescribing change amid efforts to limit the escalation of the current heroin epidemic, it is vital to identify opportunities to reduce opioid exposure for opioid-naïve patients and enhance the engagement of patients diagnosed with OUDs in treatment.

Disclosure

 The authors have no conflicts of interest to declare.

Ultrasound has been used for decades by radiology, obstetrics-gynecology, and cardiology departments within a comprehensive paradigm in which a physician enters an order, then a trained sonographer performs the study, followed by a physician evaluating and interpreting the images.¹ Unlike the traditional comprehensive paradigm, point-of-care ultrasound (POCUS) is a focused study that is both performed and interpreted by the bedside provider.² POCUS has been demonstrated to improve diagnosis and clinical management in multiple studies.^3-15

The scope of practice in POCUS differs by specialty, as POCUS is done to achieve specific procedural aims (eg, direct the needle to the correct location) or answer focused questions (eg, does the patient have a distended bladder?) related to the specialty. POCUS in hospital medicine (HM) provides immediate answers, without the delay and potential risk of transportation to other hospital areas. It may be used to diagnose pleural effusion, pneumonia, hydronephrosis, heart failure, deep vein thrombosis, and many other pathologies.^5-15 It is important to understand that POCUS performed by HM is a limited study and is not a substitute for more complete ultrasound examinations conducted in the radiology suite or in the echocardiography lab.

POCUS should not be used exclusively in medical decision making, but rather in conjunction with the greater clinical context of each patient, building on established principles of diagnosis and management.

• Credentialing: An umbrella term, which incorporates licensure, education, and certification.
• Privileging: Used to define the scope authorized for a provider by a healthcare organization based on an evaluation of the individual’s credentials and performance.
• Competency: An observable ability of a provider, integrating multiple components, such as knowledge and skills. Since competencies are observable, they can be measured and assessed to ensure their acquisition.
• Certification: The process by which an association grants recognition to a provider who has met certain predetermined qualifications specified by the association. Competence is distinguished from certification, which is defined as the process by which competence is recognized by an external agency.

All of the above mechanisms work together to provide the highest quality of reliability that a practitioner is providing safe, competent care.^16-18

Acknowledging that there are no published guidelines in the realm of HM POCUS, the development of the credentialing process at our institution is consistent with published guidelines by Emergency Medicine societies (the most established physician users of POCUS) and the American Medical Association (AMA).^19-21

The use of emergency ultrasound by physicians in the emergency department is endorsed by the American College of Emergency Physicians (ACEP).¹⁹ ACEP, along with the Society of Academic Emergency Medicine (SAEM), recommends that training in the performance and interpretation of ultrasound imaging be included during residency.²⁰ ACEP and SAEM add that the availability of equivalent training should be made available to practicing physicians. The American Society of Echocardiography has supported the use of POCUS and sees this modality as part of the continuum of care.^23,24

The AMA has also recognized that POCUS is within the scope of practice of trained physicians.²² The AMA further recommended hospital staff create their own criteria for granting ultrasound privileges based on the background and training of the physician and in accordance with the standards set within specific specialties.^22,23

The provision of clinical privileges in HM is governed by the rules and regulations of the department and institution for which privileges are sought. In detailing our policies and procedures above, we intend to provide an example for HM departments at other institutions that are attempting to create a POCUS credentialing program.

An interdisciplinary approach was created by our institution to address training, competency, and ongoing quality assurance (QA) concerns due to the increasing popularity of POCUS and variability in its use. We developed a hospital-wide POCUS committee with, among others, members from HM, emergency medicine, critical care, radiology, and cardiology, with a charter to standardize POCUS across departments. After review of the literature,^{16-18, 20, 21, 23-74} baseline training requirements were established for credentialing and developing a unified delineation of privileges for hospital-wide POCUS. The data support the use of a variety of assessments to ensure a provider has developed competence (portfolio development, knowledge-based examination, skills-based assessment, ongoing QA process). The POCUS committee identified which exams could be performed at bedside for credentialed providers, delineated imaging requirements for each exam, and set up the information technology infrastructure to support ordering and reporting through electronic health records (EHR). While the POCUS committee delineated this process for all hospital providers, we will focus our discussion on the credentialing policy and procedure in HM.

The credentialing requirements at our institution include one of the the following basic education pathways and minimal formal training:

Residency/Fellowship Based Pathway

Completed training in an Accreditation Council for Graduate Medical Education–approved program that provided opportunities for 20 hours of POCUS training with at least 6 hours of hands-on ultrasound scanning, 5 proctored limited cardiac ultrasound cases and portfolio development.

Practice Based Pathway

Completed 20 hours of POCUS continuing medical education (CME) with at least 6 hours of hands-on ultrasound scanning and has completed 5 proctored limited cardiac ultrasound cases (as part of CME).

The majority of HM providers had little formal residency training in POCUS, so a training program needed to be developed. Our training program, modeled after the American College of Chest Physicians’ CHEST certificate of completion,⁸⁶ utilizes didactic training, hands-on instruction, and portfolio development that fulfills the minimal formal requirements in the practice-based pathway.

After satisfactory completion of the minimal formal training, applicants need to provide documentation of a set number of cases. To aid this requirement, our HM department developed the portfolio guidelines in the Table. These are minimum requirements, and because of the varying training curves of learning,^76-80 1 hospitalist may need to submit 300 files for review to meet the standards, while another may need to submit 500 files. Submissions are not accepted unless they yield high-quality video files with meticulous attention to gain, depth, and appropriate topographic planes. The portfolio development monitors hospitalists’ progression during their deliberate practice, providing objective assessments, feedback, and mentorship.^81,82

A final knowledge exam with case-based image interpretation and hands-on examination is also provided. The passing score for the written examination is 85% and was based on the Angoff methodology.⁷⁵ Providers who meet these requirements are then able to apply for POCUS credentialing in HM. Providers who do not pass the final assessments are required to participate in further training before they reattempt the assessments. There is uniformity in training outcomes but diversity in training time for POCUS providers.

Candidates who complete the portfolio and satisfactorily pass the final assessments are credentialed after review by the POCUS committee. Credentialed physicians are then able to perform POCUS and to integrate the findings into patient care.

Documentation

After credentialing is obtained, all POCUS studies used in patient care are included in the EHR following a clearly defined workflow. The study is ordered through the EHR and is retrieved wirelessly on the ultrasound machine. After performing the ultrasound, all images are wirelessly transferred to the radiology Picture Archiving and Communication System server. Standardized text reports are used to distinguish focused POCUS from traditional diagnostic ultrasound studies. Documentation is optimized using electronic drop-down menus for documenting ultrasound findings in the EHR.

Minimum Number of Examinations

Maintenance of credentials will require that each hospitalist perform 10 documented ultrasounds per year for each cardiac and noncardiac application for which credentials are requested. If these numbers are not met, then all the studies performed during the previous year will be reviewed by the ultrasound committee, and providers will be provided with opportunities to meet the minimum benchmark (supervised scanning sessions).

Quality Assurance

Establishing scope of practice, developing curricula, and credentialing criteria are important steps toward assuring provider competence.^16,17,22,74 To be confident that providers are using POCUS appropriately, there must also be a development of standards of periodic assessment that encompass both examination performance and interpretation. The objective of a QA process is to evaluate the POCUS cases for technical competence and the interpretations for clinical accuracy, and to provide feedback to improve performance of providers.

QA is maintained through the interdisciplinary POCUS committee and is described in the Figure.

After initial credentialing, continued QA of HM POCUS is done for a proportion of ongoing exams (10% as per recommendations by ACEP) to document continued competency.² Credentialed POCUS providers perform and document their exam and interpretations. Ultrasound interpretations are reviewed by the POCUS committee (every case by 2 physicians, 1 hospitalist, and 1 radiologist or cardiologist depending on the study type) at appropriate intervals based on volume (at minimum, quarterly). A standardized review form is used to grade images and interpretations. This is the same general rubric used with the portfolio for initial credentialing. Each case is scored on a scale of 1 to 6, with 1 representing high image quality and support for diagnosis and 6 representing studies limited by patient factors. All scores rated 4 or 5 are reviewed at the larger quarterly POCUS committee meetings. For any provider scoring a 4 or 5, the ultrasound committee will recommend a focused professional practice evaluation as it pertains to POCUS. The committee will also make recommendations on a physician’s continued privileges to the department leaders.⁸³

Coding, billing, and reimbursement for focused ultrasound has been supported through the AMA Physicians’ Current Procedural Terminology (CPT) 2011 codes, which includes CPT code modifiers for POCUS.⁸⁴ There are significant costs associated with building a HM ultrasound program, including the education of hospitalists, ultrasound equipment purchase and maintenance, as well as image archiving and QA. The development of a HM ultrasound billing program can help justify and fund these costs.^19,85

To appropriately bill for POCUS, permanently retrievable images and an interpretation document need to be available for review. HM coders are instructed to only bill if both components are available. Because most insurers will not pay for 2 of the same type of study performed within a 24-hour period, coders do not bill for ultrasounds when a comprehensive ultrasound of the same body region is performed within a 24-hour period. The workflow that we have developed, including ordering, performing, and documenting, allows for easy coding and billing.

While POCUS has a well-established literature base in other specialties like emergency medicine, it has been a relatively recent addition to the HM specialty. As such, there exists a paucity of evidence-based medicine to support its use of POCUS in HM. While it is tempting to extrapolate from the literature of other specialties, this may not be a valid approach.

Training curves in which novice users of ultrasound become competent in specific applications are incompletely understood. Little research describes the rate of progression of learners in ultrasound towards competency. We have recently started the QA process and hope that the data will further guide feedback to the process.

Additionally, with the portfolios, the raters’ expertise may not be stable (develops through experience). We aim to mitigate this by having a group of raters reviewing each file, particularly if there is a question about if a submission is of high image quality. A notable barrier that groups face is support from their leadership regarding POCUS. Our group has had support from the chief medical officer who helped mandate the development of POCUS standards.

We have developed a robust collaborative HM POCUS program. We have noted challenges in motivating all providers to work through this protocol. Development of a POCUS program takes dedicated time, and without a champion, it is at risk for failing. HM departments would be advised to seek out willing collaborators at their institutions. We have seen that it is useful to partner with some experienced emergency medicine providers. Additionally, portfolio development and feedback has been key to demonstrating growth in image acquisition. Deliberate longitudinal practice with feedback and successive refinements with POCUS obtain the highest yield towards competency. We hope our QA data will provide further feedback into the credentialing policy and procedure.

It is important that POCUS users work together to recognize its potential and limitations, teach current and future care providers’ best practices, and create an infrastructure that maximizes quality of care while minimizing patient risk.

We are hopeful that this document will prove beneficial to other HM departments in the development of successful POCUS programs. We feel that it is important to make available to other HM departments a concise protocol that has successfully passed through the credentialing process at a large tertiary care medical system.

Acknowledgments

The authors would like to acknowledge Susan Truman, MD, for her contributions to the success of the POCUS committee at Regions Hospital. The authors would like to acknowledge Kreegan Reierson, MD, Ankit Mehta, MBBS, and Khuong Vuong, MD for their contributions to the success of POCUS within hospital medicine at HealthPartners. The authors would like to acknowledge Sandi Wewerka, MPH, for her review and input of this manuscript.

Disclosure

The authors do not have any relevant financial disclosures to report.

Ultrasound has been used for decades by radiology, obstetrics-gynecology, and cardiology departments within a comprehensive paradigm in which a physician enters an order, then a trained sonographer performs the study, followed by a physician evaluating and interpreting the images.¹ Unlike the traditional comprehensive paradigm, point-of-care ultrasound (POCUS) is a focused study that is both performed and interpreted by the bedside provider.² POCUS has been demonstrated to improve diagnosis and clinical management in multiple studies.^3-15

The scope of practice in POCUS differs by specialty, as POCUS is done to achieve specific procedural aims (eg, direct the needle to the correct location) or answer focused questions (eg, does the patient have a distended bladder?) related to the specialty. POCUS in hospital medicine (HM) provides immediate answers, without the delay and potential risk of transportation to other hospital areas. It may be used to diagnose pleural effusion, pneumonia, hydronephrosis, heart failure, deep vein thrombosis, and many other pathologies.^5-15 It is important to understand that POCUS performed by HM is a limited study and is not a substitute for more complete ultrasound examinations conducted in the radiology suite or in the echocardiography lab.

POCUS should not be used exclusively in medical decision making, but rather in conjunction with the greater clinical context of each patient, building on established principles of diagnosis and management.

• Credentialing: An umbrella term, which incorporates licensure, education, and certification.
• Privileging: Used to define the scope authorized for a provider by a healthcare organization based on an evaluation of the individual’s credentials and performance.
• Competency: An observable ability of a provider, integrating multiple components, such as knowledge and skills. Since competencies are observable, they can be measured and assessed to ensure their acquisition.
• Certification: The process by which an association grants recognition to a provider who has met certain predetermined qualifications specified by the association. Competence is distinguished from certification, which is defined as the process by which competence is recognized by an external agency.

All of the above mechanisms work together to provide the highest quality of reliability that a practitioner is providing safe, competent care.^16-18

Acknowledging that there are no published guidelines in the realm of HM POCUS, the development of the credentialing process at our institution is consistent with published guidelines by Emergency Medicine societies (the most established physician users of POCUS) and the American Medical Association (AMA).^19-21

The use of emergency ultrasound by physicians in the emergency department is endorsed by the American College of Emergency Physicians (ACEP).¹⁹ ACEP, along with the Society of Academic Emergency Medicine (SAEM), recommends that training in the performance and interpretation of ultrasound imaging be included during residency.²⁰ ACEP and SAEM add that the availability of equivalent training should be made available to practicing physicians. The American Society of Echocardiography has supported the use of POCUS and sees this modality as part of the continuum of care.^23,24

The AMA has also recognized that POCUS is within the scope of practice of trained physicians.²² The AMA further recommended hospital staff create their own criteria for granting ultrasound privileges based on the background and training of the physician and in accordance with the standards set within specific specialties.^22,23

The provision of clinical privileges in HM is governed by the rules and regulations of the department and institution for which privileges are sought. In detailing our policies and procedures above, we intend to provide an example for HM departments at other institutions that are attempting to create a POCUS credentialing program.

An interdisciplinary approach was created by our institution to address training, competency, and ongoing quality assurance (QA) concerns due to the increasing popularity of POCUS and variability in its use. We developed a hospital-wide POCUS committee with, among others, members from HM, emergency medicine, critical care, radiology, and cardiology, with a charter to standardize POCUS across departments. After review of the literature,^{16-18, 20, 21, 23-74} baseline training requirements were established for credentialing and developing a unified delineation of privileges for hospital-wide POCUS. The data support the use of a variety of assessments to ensure a provider has developed competence (portfolio development, knowledge-based examination, skills-based assessment, ongoing QA process). The POCUS committee identified which exams could be performed at bedside for credentialed providers, delineated imaging requirements for each exam, and set up the information technology infrastructure to support ordering and reporting through electronic health records (EHR). While the POCUS committee delineated this process for all hospital providers, we will focus our discussion on the credentialing policy and procedure in HM.

The credentialing requirements at our institution include one of the the following basic education pathways and minimal formal training:

Residency/Fellowship Based Pathway

Completed training in an Accreditation Council for Graduate Medical Education–approved program that provided opportunities for 20 hours of POCUS training with at least 6 hours of hands-on ultrasound scanning, 5 proctored limited cardiac ultrasound cases and portfolio development.

Practice Based Pathway

Completed 20 hours of POCUS continuing medical education (CME) with at least 6 hours of hands-on ultrasound scanning and has completed 5 proctored limited cardiac ultrasound cases (as part of CME).

The majority of HM providers had little formal residency training in POCUS, so a training program needed to be developed. Our training program, modeled after the American College of Chest Physicians’ CHEST certificate of completion,⁸⁶ utilizes didactic training, hands-on instruction, and portfolio development that fulfills the minimal formal requirements in the practice-based pathway.

After satisfactory completion of the minimal formal training, applicants need to provide documentation of a set number of cases. To aid this requirement, our HM department developed the portfolio guidelines in the Table. These are minimum requirements, and because of the varying training curves of learning,^76-80 1 hospitalist may need to submit 300 files for review to meet the standards, while another may need to submit 500 files. Submissions are not accepted unless they yield high-quality video files with meticulous attention to gain, depth, and appropriate topographic planes. The portfolio development monitors hospitalists’ progression during their deliberate practice, providing objective assessments, feedback, and mentorship.^81,82

A final knowledge exam with case-based image interpretation and hands-on examination is also provided. The passing score for the written examination is 85% and was based on the Angoff methodology.⁷⁵ Providers who meet these requirements are then able to apply for POCUS credentialing in HM. Providers who do not pass the final assessments are required to participate in further training before they reattempt the assessments. There is uniformity in training outcomes but diversity in training time for POCUS providers.

Candidates who complete the portfolio and satisfactorily pass the final assessments are credentialed after review by the POCUS committee. Credentialed physicians are then able to perform POCUS and to integrate the findings into patient care.

Documentation

After credentialing is obtained, all POCUS studies used in patient care are included in the EHR following a clearly defined workflow. The study is ordered through the EHR and is retrieved wirelessly on the ultrasound machine. After performing the ultrasound, all images are wirelessly transferred to the radiology Picture Archiving and Communication System server. Standardized text reports are used to distinguish focused POCUS from traditional diagnostic ultrasound studies. Documentation is optimized using electronic drop-down menus for documenting ultrasound findings in the EHR.

Minimum Number of Examinations

Maintenance of credentials will require that each hospitalist perform 10 documented ultrasounds per year for each cardiac and noncardiac application for which credentials are requested. If these numbers are not met, then all the studies performed during the previous year will be reviewed by the ultrasound committee, and providers will be provided with opportunities to meet the minimum benchmark (supervised scanning sessions).

Quality Assurance

Establishing scope of practice, developing curricula, and credentialing criteria are important steps toward assuring provider competence.^16,17,22,74 To be confident that providers are using POCUS appropriately, there must also be a development of standards of periodic assessment that encompass both examination performance and interpretation. The objective of a QA process is to evaluate the POCUS cases for technical competence and the interpretations for clinical accuracy, and to provide feedback to improve performance of providers.

QA is maintained through the interdisciplinary POCUS committee and is described in the Figure.

After initial credentialing, continued QA of HM POCUS is done for a proportion of ongoing exams (10% as per recommendations by ACEP) to document continued competency.² Credentialed POCUS providers perform and document their exam and interpretations. Ultrasound interpretations are reviewed by the POCUS committee (every case by 2 physicians, 1 hospitalist, and 1 radiologist or cardiologist depending on the study type) at appropriate intervals based on volume (at minimum, quarterly). A standardized review form is used to grade images and interpretations. This is the same general rubric used with the portfolio for initial credentialing. Each case is scored on a scale of 1 to 6, with 1 representing high image quality and support for diagnosis and 6 representing studies limited by patient factors. All scores rated 4 or 5 are reviewed at the larger quarterly POCUS committee meetings. For any provider scoring a 4 or 5, the ultrasound committee will recommend a focused professional practice evaluation as it pertains to POCUS. The committee will also make recommendations on a physician’s continued privileges to the department leaders.⁸³

Coding, billing, and reimbursement for focused ultrasound has been supported through the AMA Physicians’ Current Procedural Terminology (CPT) 2011 codes, which includes CPT code modifiers for POCUS.⁸⁴ There are significant costs associated with building a HM ultrasound program, including the education of hospitalists, ultrasound equipment purchase and maintenance, as well as image archiving and QA. The development of a HM ultrasound billing program can help justify and fund these costs.^19,85

To appropriately bill for POCUS, permanently retrievable images and an interpretation document need to be available for review. HM coders are instructed to only bill if both components are available. Because most insurers will not pay for 2 of the same type of study performed within a 24-hour period, coders do not bill for ultrasounds when a comprehensive ultrasound of the same body region is performed within a 24-hour period. The workflow that we have developed, including ordering, performing, and documenting, allows for easy coding and billing.

While POCUS has a well-established literature base in other specialties like emergency medicine, it has been a relatively recent addition to the HM specialty. As such, there exists a paucity of evidence-based medicine to support its use of POCUS in HM. While it is tempting to extrapolate from the literature of other specialties, this may not be a valid approach.

Training curves in which novice users of ultrasound become competent in specific applications are incompletely understood. Little research describes the rate of progression of learners in ultrasound towards competency. We have recently started the QA process and hope that the data will further guide feedback to the process.

Additionally, with the portfolios, the raters’ expertise may not be stable (develops through experience). We aim to mitigate this by having a group of raters reviewing each file, particularly if there is a question about if a submission is of high image quality. A notable barrier that groups face is support from their leadership regarding POCUS. Our group has had support from the chief medical officer who helped mandate the development of POCUS standards.

We have developed a robust collaborative HM POCUS program. We have noted challenges in motivating all providers to work through this protocol. Development of a POCUS program takes dedicated time, and without a champion, it is at risk for failing. HM departments would be advised to seek out willing collaborators at their institutions. We have seen that it is useful to partner with some experienced emergency medicine providers. Additionally, portfolio development and feedback has been key to demonstrating growth in image acquisition. Deliberate longitudinal practice with feedback and successive refinements with POCUS obtain the highest yield towards competency. We hope our QA data will provide further feedback into the credentialing policy and procedure.

It is important that POCUS users work together to recognize its potential and limitations, teach current and future care providers’ best practices, and create an infrastructure that maximizes quality of care while minimizing patient risk.

We are hopeful that this document will prove beneficial to other HM departments in the development of successful POCUS programs. We feel that it is important to make available to other HM departments a concise protocol that has successfully passed through the credentialing process at a large tertiary care medical system.

Acknowledgments

The authors would like to acknowledge Susan Truman, MD, for her contributions to the success of the POCUS committee at Regions Hospital. The authors would like to acknowledge Kreegan Reierson, MD, Ankit Mehta, MBBS, and Khuong Vuong, MD for their contributions to the success of POCUS within hospital medicine at HealthPartners. The authors would like to acknowledge Sandi Wewerka, MPH, for her review and input of this manuscript.

Disclosure

The authors do not have any relevant financial disclosures to report.

Ultrasound has been used for decades by radiology, obstetrics-gynecology, and cardiology departments within a comprehensive paradigm in which a physician enters an order, then a trained sonographer performs the study, followed by a physician evaluating and interpreting the images.¹ Unlike the traditional comprehensive paradigm, point-of-care ultrasound (POCUS) is a focused study that is both performed and interpreted by the bedside provider.² POCUS has been demonstrated to improve diagnosis and clinical management in multiple studies.^3-15

The scope of practice in POCUS differs by specialty, as POCUS is done to achieve specific procedural aims (eg, direct the needle to the correct location) or answer focused questions (eg, does the patient have a distended bladder?) related to the specialty. POCUS in hospital medicine (HM) provides immediate answers, without the delay and potential risk of transportation to other hospital areas. It may be used to diagnose pleural effusion, pneumonia, hydronephrosis, heart failure, deep vein thrombosis, and many other pathologies.^5-15 It is important to understand that POCUS performed by HM is a limited study and is not a substitute for more complete ultrasound examinations conducted in the radiology suite or in the echocardiography lab.

POCUS should not be used exclusively in medical decision making, but rather in conjunction with the greater clinical context of each patient, building on established principles of diagnosis and management.

• Credentialing: An umbrella term, which incorporates licensure, education, and certification.
• Privileging: Used to define the scope authorized for a provider by a healthcare organization based on an evaluation of the individual’s credentials and performance.
• Competency: An observable ability of a provider, integrating multiple components, such as knowledge and skills. Since competencies are observable, they can be measured and assessed to ensure their acquisition.
• Certification: The process by which an association grants recognition to a provider who has met certain predetermined qualifications specified by the association. Competence is distinguished from certification, which is defined as the process by which competence is recognized by an external agency.

All of the above mechanisms work together to provide the highest quality of reliability that a practitioner is providing safe, competent care.^16-18

Acknowledging that there are no published guidelines in the realm of HM POCUS, the development of the credentialing process at our institution is consistent with published guidelines by Emergency Medicine societies (the most established physician users of POCUS) and the American Medical Association (AMA).^19-21

The use of emergency ultrasound by physicians in the emergency department is endorsed by the American College of Emergency Physicians (ACEP).¹⁹ ACEP, along with the Society of Academic Emergency Medicine (SAEM), recommends that training in the performance and interpretation of ultrasound imaging be included during residency.²⁰ ACEP and SAEM add that the availability of equivalent training should be made available to practicing physicians. The American Society of Echocardiography has supported the use of POCUS and sees this modality as part of the continuum of care.^23,24

The AMA has also recognized that POCUS is within the scope of practice of trained physicians.²² The AMA further recommended hospital staff create their own criteria for granting ultrasound privileges based on the background and training of the physician and in accordance with the standards set within specific specialties.^22,23

The provision of clinical privileges in HM is governed by the rules and regulations of the department and institution for which privileges are sought. In detailing our policies and procedures above, we intend to provide an example for HM departments at other institutions that are attempting to create a POCUS credentialing program.

An interdisciplinary approach was created by our institution to address training, competency, and ongoing quality assurance (QA) concerns due to the increasing popularity of POCUS and variability in its use. We developed a hospital-wide POCUS committee with, among others, members from HM, emergency medicine, critical care, radiology, and cardiology, with a charter to standardize POCUS across departments. After review of the literature,^{16-18, 20, 21, 23-74} baseline training requirements were established for credentialing and developing a unified delineation of privileges for hospital-wide POCUS. The data support the use of a variety of assessments to ensure a provider has developed competence (portfolio development, knowledge-based examination, skills-based assessment, ongoing QA process). The POCUS committee identified which exams could be performed at bedside for credentialed providers, delineated imaging requirements for each exam, and set up the information technology infrastructure to support ordering and reporting through electronic health records (EHR). While the POCUS committee delineated this process for all hospital providers, we will focus our discussion on the credentialing policy and procedure in HM.

The credentialing requirements at our institution include one of the the following basic education pathways and minimal formal training:

Residency/Fellowship Based Pathway

Completed training in an Accreditation Council for Graduate Medical Education–approved program that provided opportunities for 20 hours of POCUS training with at least 6 hours of hands-on ultrasound scanning, 5 proctored limited cardiac ultrasound cases and portfolio development.

Practice Based Pathway

Completed 20 hours of POCUS continuing medical education (CME) with at least 6 hours of hands-on ultrasound scanning and has completed 5 proctored limited cardiac ultrasound cases (as part of CME).

The majority of HM providers had little formal residency training in POCUS, so a training program needed to be developed. Our training program, modeled after the American College of Chest Physicians’ CHEST certificate of completion,⁸⁶ utilizes didactic training, hands-on instruction, and portfolio development that fulfills the minimal formal requirements in the practice-based pathway.

After satisfactory completion of the minimal formal training, applicants need to provide documentation of a set number of cases. To aid this requirement, our HM department developed the portfolio guidelines in the Table. These are minimum requirements, and because of the varying training curves of learning,^76-80 1 hospitalist may need to submit 300 files for review to meet the standards, while another may need to submit 500 files. Submissions are not accepted unless they yield high-quality video files with meticulous attention to gain, depth, and appropriate topographic planes. The portfolio development monitors hospitalists’ progression during their deliberate practice, providing objective assessments, feedback, and mentorship.^81,82

A final knowledge exam with case-based image interpretation and hands-on examination is also provided. The passing score for the written examination is 85% and was based on the Angoff methodology.⁷⁵ Providers who meet these requirements are then able to apply for POCUS credentialing in HM. Providers who do not pass the final assessments are required to participate in further training before they reattempt the assessments. There is uniformity in training outcomes but diversity in training time for POCUS providers.

Candidates who complete the portfolio and satisfactorily pass the final assessments are credentialed after review by the POCUS committee. Credentialed physicians are then able to perform POCUS and to integrate the findings into patient care.

Documentation

After credentialing is obtained, all POCUS studies used in patient care are included in the EHR following a clearly defined workflow. The study is ordered through the EHR and is retrieved wirelessly on the ultrasound machine. After performing the ultrasound, all images are wirelessly transferred to the radiology Picture Archiving and Communication System server. Standardized text reports are used to distinguish focused POCUS from traditional diagnostic ultrasound studies. Documentation is optimized using electronic drop-down menus for documenting ultrasound findings in the EHR.

Minimum Number of Examinations

Maintenance of credentials will require that each hospitalist perform 10 documented ultrasounds per year for each cardiac and noncardiac application for which credentials are requested. If these numbers are not met, then all the studies performed during the previous year will be reviewed by the ultrasound committee, and providers will be provided with opportunities to meet the minimum benchmark (supervised scanning sessions).

Quality Assurance

Establishing scope of practice, developing curricula, and credentialing criteria are important steps toward assuring provider competence.^16,17,22,74 To be confident that providers are using POCUS appropriately, there must also be a development of standards of periodic assessment that encompass both examination performance and interpretation. The objective of a QA process is to evaluate the POCUS cases for technical competence and the interpretations for clinical accuracy, and to provide feedback to improve performance of providers.

QA is maintained through the interdisciplinary POCUS committee and is described in the Figure.

After initial credentialing, continued QA of HM POCUS is done for a proportion of ongoing exams (10% as per recommendations by ACEP) to document continued competency.² Credentialed POCUS providers perform and document their exam and interpretations. Ultrasound interpretations are reviewed by the POCUS committee (every case by 2 physicians, 1 hospitalist, and 1 radiologist or cardiologist depending on the study type) at appropriate intervals based on volume (at minimum, quarterly). A standardized review form is used to grade images and interpretations. This is the same general rubric used with the portfolio for initial credentialing. Each case is scored on a scale of 1 to 6, with 1 representing high image quality and support for diagnosis and 6 representing studies limited by patient factors. All scores rated 4 or 5 are reviewed at the larger quarterly POCUS committee meetings. For any provider scoring a 4 or 5, the ultrasound committee will recommend a focused professional practice evaluation as it pertains to POCUS. The committee will also make recommendations on a physician’s continued privileges to the department leaders.⁸³

Coding, billing, and reimbursement for focused ultrasound has been supported through the AMA Physicians’ Current Procedural Terminology (CPT) 2011 codes, which includes CPT code modifiers for POCUS.⁸⁴ There are significant costs associated with building a HM ultrasound program, including the education of hospitalists, ultrasound equipment purchase and maintenance, as well as image archiving and QA. The development of a HM ultrasound billing program can help justify and fund these costs.^19,85

To appropriately bill for POCUS, permanently retrievable images and an interpretation document need to be available for review. HM coders are instructed to only bill if both components are available. Because most insurers will not pay for 2 of the same type of study performed within a 24-hour period, coders do not bill for ultrasounds when a comprehensive ultrasound of the same body region is performed within a 24-hour period. The workflow that we have developed, including ordering, performing, and documenting, allows for easy coding and billing.

While POCUS has a well-established literature base in other specialties like emergency medicine, it has been a relatively recent addition to the HM specialty. As such, there exists a paucity of evidence-based medicine to support its use of POCUS in HM. While it is tempting to extrapolate from the literature of other specialties, this may not be a valid approach.

Training curves in which novice users of ultrasound become competent in specific applications are incompletely understood. Little research describes the rate of progression of learners in ultrasound towards competency. We have recently started the QA process and hope that the data will further guide feedback to the process.

Additionally, with the portfolios, the raters’ expertise may not be stable (develops through experience). We aim to mitigate this by having a group of raters reviewing each file, particularly if there is a question about if a submission is of high image quality. A notable barrier that groups face is support from their leadership regarding POCUS. Our group has had support from the chief medical officer who helped mandate the development of POCUS standards.

We have developed a robust collaborative HM POCUS program. We have noted challenges in motivating all providers to work through this protocol. Development of a POCUS program takes dedicated time, and without a champion, it is at risk for failing. HM departments would be advised to seek out willing collaborators at their institutions. We have seen that it is useful to partner with some experienced emergency medicine providers. Additionally, portfolio development and feedback has been key to demonstrating growth in image acquisition. Deliberate longitudinal practice with feedback and successive refinements with POCUS obtain the highest yield towards competency. We hope our QA data will provide further feedback into the credentialing policy and procedure.

It is important that POCUS users work together to recognize its potential and limitations, teach current and future care providers’ best practices, and create an infrastructure that maximizes quality of care while minimizing patient risk.

We are hopeful that this document will prove beneficial to other HM departments in the development of successful POCUS programs. We feel that it is important to make available to other HM departments a concise protocol that has successfully passed through the credentialing process at a large tertiary care medical system.

Acknowledgments

The authors would like to acknowledge Susan Truman, MD, for her contributions to the success of the POCUS committee at Regions Hospital. The authors would like to acknowledge Kreegan Reierson, MD, Ankit Mehta, MBBS, and Khuong Vuong, MD for their contributions to the success of POCUS within hospital medicine at HealthPartners. The authors would like to acknowledge Sandi Wewerka, MPH, for her review and input of this manuscript.

Disclosure

The authors do not have any relevant financial disclosures to report.