Cheryl Clark

SAN DIEGO – Hospitalists should evaluate their patients for aspiration syndrome and swallowing difficulty, known as dysphagia, more carefully than they now do, says a hospitalist at the Atlanta VA Medical Center.

Dr. Anna Von, a staff physician in the hospital medicine section at the Atlanta VA, spoke about the challenges of managing inpatient dysphagia at the annual meeting of the Society of Hospital Medicine. Her talk was entitled “Hard to Swallow: Dysphagia, Aspiration Syndromes, and Tube-Feeding Decisions for Inpatient Providers.”

©Eraxion/Thinkstock.com

Dysphagia affects as many as one in four inpatients overall and nearly half of frail seniors, she said. In addition, 75% of elderly patients with pneumonia have dysphagia.

Some patients may be appropriate for feeding tubes to prevent aspiration, depending on their condition, Dr. Von explained, but most of the time, feeding tubes may do more harm than good. Much of the time, modified diets and adjustments in the way patients eat or are fed may provide nutrition more safely than feeding tubes.

In a follow-up phone interview, Dr. Von elaborated on her presentation.

“In many advanced disease states, the burden of a feeding tube far outweighs any benefit,” she said. “It’s important to get a speech pathology evaluation to determine if the patient has a swallowing or aspiration issue, determine the extent, and suggest appropriate treatment.”

Dr. Von also said that calling for a speech pathologist to evaluate a patient one time may not be enough. “A lot of the time our physicians look for the speech pathologist to either pass or fail their patient, and if they pass, they say ‘good to go. I don’t need to worry about this anymore,’ and if they fail, they consider alternate means of nutrition, such as a feeding tube.”

“But it’s really more than just a pass-fail question,” she said. “There’s going to be degrees of severity in dysphagia; some people may benefit from a modified diet of a different consistency, and many benefit from different techniques they can use while swallowing that will increase efficiency of the swallow.”

For example, sometimes having a patient turn his or her head slightly when trying to swallow, especially if one side is impaired by stroke, may help them use muscles that are stronger on the other side, Dr. Von said.

Patients with dysphagia, however, “will always be at risk of having an aspiration complication,” she said. “And that should be well communicated.”

Providing nutrition arises frequently with families whose loved ones have forgotten how to swallow, or have lost muscle and nerve coordination due to their age or disease. They may think tube feeding will provide essential nutrition, prolong survival and help heal and prevent pressure ulcers. But they usually don’t, Dr. Von said.

“That’s exactly what we deal with on a day-to-day basis, the underlying emotional conflict: our instincts as humans and as caregivers to feed,” she explained. “But sometimes tube feeding offers more burden than benefit, and that’s hard to let go.” This is often a tough reality for families to comprehend, especially with advanced stages of disease, and hospitalists should consider having palliative care discussions rather than placing feeding tubes at the appropriate time.

Careful, monitored hand-feeding may at times be appropriate. There is an aspiration risk, Dr. Von said, but if the patient is given sufficient time to swallow each bite, and caregivers pay close attention to cues from the patient that they would like to eat, or that they’re not interested, hand feeding is usually a better alternative.

Changing Practice

Several studies, particularly one Dr. Von called “groundbreaking” in the Archives of Internal Medicine in 2012, found that for pressure ulcers, “feeding tubes offer no benefit and in fact may be associated with increased risk for pressure ulcers in patients with advanced dementia.”

Feeding tubes may require restraints and discourage mobility that helps wounds heal, but many practicing physicians do not understand that, she said. Numerous other studies found that feeding tubes do not improve survival or prevent aspiration pneumonia.

Nevertheless, feeding tube placement for patients with advanced dementia continues to be a common occurrence nationally, despite recommendations to the contrary, according to a February report from the Dartmouth Atlas. Using Medicare claims data, the report found that nationally in 2012, 6% of patients with advanced dementia had a feeding tube placed during their last six months of life, with regional rates varying widely.

Dr. Von speculated that feeding tube placement orders are often placed “as a default” for the interventional radiologist or gastroenterologist. “Once the order is written, the feeding tube gets placed, like a medication that’s just given rather than having a discussion about it,” she said. However, feeding tubes are often appropriate for patients with head and neck cancers, even if they’re advanced, she said. “That’s a different special case.”

There are treatment differences for aspiration pneumonia, an infection when there’s bacteria in the aspirated volume that goes into the airway, and aspiration pneumonitis, which is a chemical burn when acidic gastric contents are regurgitated and aspirated into the airway.

“The bottom line is that with aspiration pneumonia, antibiotics and supportive respiratory therapy are the mainstays of therapy and what’s recommended,” she said, whereas with pneumonitis, the patient usually does not require antibiotics, just supportive therapy. Choice of antibiotics depends on whether the patient’s aspiration pneumonia was acquired in a healthcare setting, which may mean they’re colonized with a bacteria that is more likely drug-resistant, versus a community or home setting.

Dr. Von became interested in dysphagia and aspiration complications after her residency training, when she began practicing and “discovered I didn’t know a lot about aspiration syndromes, how to treat them or evaluate dysphagia.” She also discovered she wasn’t alone.

Dr. Von reported no financial conflicts.

SAN DIEGO – Hospitalists should evaluate their patients for aspiration syndrome and swallowing difficulty, known as dysphagia, more carefully than they now do, says a hospitalist at the Atlanta VA Medical Center.

Dr. Anna Von, a staff physician in the hospital medicine section at the Atlanta VA, spoke about the challenges of managing inpatient dysphagia at the annual meeting of the Society of Hospital Medicine. Her talk was entitled “Hard to Swallow: Dysphagia, Aspiration Syndromes, and Tube-Feeding Decisions for Inpatient Providers.”

©Eraxion/Thinkstock.com

Dysphagia affects as many as one in four inpatients overall and nearly half of frail seniors, she said. In addition, 75% of elderly patients with pneumonia have dysphagia.

Some patients may be appropriate for feeding tubes to prevent aspiration, depending on their condition, Dr. Von explained, but most of the time, feeding tubes may do more harm than good. Much of the time, modified diets and adjustments in the way patients eat or are fed may provide nutrition more safely than feeding tubes.

In a follow-up phone interview, Dr. Von elaborated on her presentation.

“In many advanced disease states, the burden of a feeding tube far outweighs any benefit,” she said. “It’s important to get a speech pathology evaluation to determine if the patient has a swallowing or aspiration issue, determine the extent, and suggest appropriate treatment.”

Dr. Von also said that calling for a speech pathologist to evaluate a patient one time may not be enough. “A lot of the time our physicians look for the speech pathologist to either pass or fail their patient, and if they pass, they say ‘good to go. I don’t need to worry about this anymore,’ and if they fail, they consider alternate means of nutrition, such as a feeding tube.”

“But it’s really more than just a pass-fail question,” she said. “There’s going to be degrees of severity in dysphagia; some people may benefit from a modified diet of a different consistency, and many benefit from different techniques they can use while swallowing that will increase efficiency of the swallow.”

For example, sometimes having a patient turn his or her head slightly when trying to swallow, especially if one side is impaired by stroke, may help them use muscles that are stronger on the other side, Dr. Von said.

Patients with dysphagia, however, “will always be at risk of having an aspiration complication,” she said. “And that should be well communicated.”

Providing nutrition arises frequently with families whose loved ones have forgotten how to swallow, or have lost muscle and nerve coordination due to their age or disease. They may think tube feeding will provide essential nutrition, prolong survival and help heal and prevent pressure ulcers. But they usually don’t, Dr. Von said.

“That’s exactly what we deal with on a day-to-day basis, the underlying emotional conflict: our instincts as humans and as caregivers to feed,” she explained. “But sometimes tube feeding offers more burden than benefit, and that’s hard to let go.” This is often a tough reality for families to comprehend, especially with advanced stages of disease, and hospitalists should consider having palliative care discussions rather than placing feeding tubes at the appropriate time.

Careful, monitored hand-feeding may at times be appropriate. There is an aspiration risk, Dr. Von said, but if the patient is given sufficient time to swallow each bite, and caregivers pay close attention to cues from the patient that they would like to eat, or that they’re not interested, hand feeding is usually a better alternative.

Changing Practice

Several studies, particularly one Dr. Von called “groundbreaking” in the Archives of Internal Medicine in 2012, found that for pressure ulcers, “feeding tubes offer no benefit and in fact may be associated with increased risk for pressure ulcers in patients with advanced dementia.”

Feeding tubes may require restraints and discourage mobility that helps wounds heal, but many practicing physicians do not understand that, she said. Numerous other studies found that feeding tubes do not improve survival or prevent aspiration pneumonia.

Nevertheless, feeding tube placement for patients with advanced dementia continues to be a common occurrence nationally, despite recommendations to the contrary, according to a February report from the Dartmouth Atlas. Using Medicare claims data, the report found that nationally in 2012, 6% of patients with advanced dementia had a feeding tube placed during their last six months of life, with regional rates varying widely.

Dr. Von speculated that feeding tube placement orders are often placed “as a default” for the interventional radiologist or gastroenterologist. “Once the order is written, the feeding tube gets placed, like a medication that’s just given rather than having a discussion about it,” she said. However, feeding tubes are often appropriate for patients with head and neck cancers, even if they’re advanced, she said. “That’s a different special case.”

There are treatment differences for aspiration pneumonia, an infection when there’s bacteria in the aspirated volume that goes into the airway, and aspiration pneumonitis, which is a chemical burn when acidic gastric contents are regurgitated and aspirated into the airway.

“The bottom line is that with aspiration pneumonia, antibiotics and supportive respiratory therapy are the mainstays of therapy and what’s recommended,” she said, whereas with pneumonitis, the patient usually does not require antibiotics, just supportive therapy. Choice of antibiotics depends on whether the patient’s aspiration pneumonia was acquired in a healthcare setting, which may mean they’re colonized with a bacteria that is more likely drug-resistant, versus a community or home setting.

Dr. Von became interested in dysphagia and aspiration complications after her residency training, when she began practicing and “discovered I didn’t know a lot about aspiration syndromes, how to treat them or evaluate dysphagia.” She also discovered she wasn’t alone.

Dr. Von reported no financial conflicts.

SAN DIEGO – Hospitalists should evaluate their patients for aspiration syndrome and swallowing difficulty, known as dysphagia, more carefully than they now do, says a hospitalist at the Atlanta VA Medical Center.

Dr. Anna Von, a staff physician in the hospital medicine section at the Atlanta VA, spoke about the challenges of managing inpatient dysphagia at the annual meeting of the Society of Hospital Medicine. Her talk was entitled “Hard to Swallow: Dysphagia, Aspiration Syndromes, and Tube-Feeding Decisions for Inpatient Providers.”

©Eraxion/Thinkstock.com

Dysphagia affects as many as one in four inpatients overall and nearly half of frail seniors, she said. In addition, 75% of elderly patients with pneumonia have dysphagia.

Some patients may be appropriate for feeding tubes to prevent aspiration, depending on their condition, Dr. Von explained, but most of the time, feeding tubes may do more harm than good. Much of the time, modified diets and adjustments in the way patients eat or are fed may provide nutrition more safely than feeding tubes.

In a follow-up phone interview, Dr. Von elaborated on her presentation.

“In many advanced disease states, the burden of a feeding tube far outweighs any benefit,” she said. “It’s important to get a speech pathology evaluation to determine if the patient has a swallowing or aspiration issue, determine the extent, and suggest appropriate treatment.”

Dr. Von also said that calling for a speech pathologist to evaluate a patient one time may not be enough. “A lot of the time our physicians look for the speech pathologist to either pass or fail their patient, and if they pass, they say ‘good to go. I don’t need to worry about this anymore,’ and if they fail, they consider alternate means of nutrition, such as a feeding tube.”

“But it’s really more than just a pass-fail question,” she said. “There’s going to be degrees of severity in dysphagia; some people may benefit from a modified diet of a different consistency, and many benefit from different techniques they can use while swallowing that will increase efficiency of the swallow.”

For example, sometimes having a patient turn his or her head slightly when trying to swallow, especially if one side is impaired by stroke, may help them use muscles that are stronger on the other side, Dr. Von said.

Patients with dysphagia, however, “will always be at risk of having an aspiration complication,” she said. “And that should be well communicated.”

Providing nutrition arises frequently with families whose loved ones have forgotten how to swallow, or have lost muscle and nerve coordination due to their age or disease. They may think tube feeding will provide essential nutrition, prolong survival and help heal and prevent pressure ulcers. But they usually don’t, Dr. Von said.

“That’s exactly what we deal with on a day-to-day basis, the underlying emotional conflict: our instincts as humans and as caregivers to feed,” she explained. “But sometimes tube feeding offers more burden than benefit, and that’s hard to let go.” This is often a tough reality for families to comprehend, especially with advanced stages of disease, and hospitalists should consider having palliative care discussions rather than placing feeding tubes at the appropriate time.

Careful, monitored hand-feeding may at times be appropriate. There is an aspiration risk, Dr. Von said, but if the patient is given sufficient time to swallow each bite, and caregivers pay close attention to cues from the patient that they would like to eat, or that they’re not interested, hand feeding is usually a better alternative.

Changing Practice

Several studies, particularly one Dr. Von called “groundbreaking” in the Archives of Internal Medicine in 2012, found that for pressure ulcers, “feeding tubes offer no benefit and in fact may be associated with increased risk for pressure ulcers in patients with advanced dementia.”

Feeding tubes may require restraints and discourage mobility that helps wounds heal, but many practicing physicians do not understand that, she said. Numerous other studies found that feeding tubes do not improve survival or prevent aspiration pneumonia.

Nevertheless, feeding tube placement for patients with advanced dementia continues to be a common occurrence nationally, despite recommendations to the contrary, according to a February report from the Dartmouth Atlas. Using Medicare claims data, the report found that nationally in 2012, 6% of patients with advanced dementia had a feeding tube placed during their last six months of life, with regional rates varying widely.

Dr. Von speculated that feeding tube placement orders are often placed “as a default” for the interventional radiologist or gastroenterologist. “Once the order is written, the feeding tube gets placed, like a medication that’s just given rather than having a discussion about it,” she said. However, feeding tubes are often appropriate for patients with head and neck cancers, even if they’re advanced, she said. “That’s a different special case.”

There are treatment differences for aspiration pneumonia, an infection when there’s bacteria in the aspirated volume that goes into the airway, and aspiration pneumonitis, which is a chemical burn when acidic gastric contents are regurgitated and aspirated into the airway.

“The bottom line is that with aspiration pneumonia, antibiotics and supportive respiratory therapy are the mainstays of therapy and what’s recommended,” she said, whereas with pneumonitis, the patient usually does not require antibiotics, just supportive therapy. Choice of antibiotics depends on whether the patient’s aspiration pneumonia was acquired in a healthcare setting, which may mean they’re colonized with a bacteria that is more likely drug-resistant, versus a community or home setting.

Dr. Von became interested in dysphagia and aspiration complications after her residency training, when she began practicing and “discovered I didn’t know a lot about aspiration syndromes, how to treat them or evaluate dysphagia.” She also discovered she wasn’t alone.

Dr. Von reported no financial conflicts.

Can a new medical school, with an unprecedented curriculum focused intensely on costs and value, employing teams that include nurses, pharmacists, and social workers, improve the health of Austin, Tex., and set a new standard for medical education?

That’s what leaders of Dell Medical School at the University of Texas at Austin promise to do, as they welcome the first class of 50 medical students in June.

The new school’s leaders convinced 55% of Travis County, Tex., voters in 2012 to pay higher property taxes to help support it. They’ll pay 5 cents more per $100 of assessed valuation, generating $54 million a year, about $35 million of which will go for the school, and for caring for underserved patients.

That’s unprecedented, said school officials. Dell Med is the only medical school in the country to receive a significant share of its funds from local property taxpayers approved by vote.

“Austin is unique. Austin is weird,” said Dr. Susan Cox, Dell Medical School’s executive vice dean of academics and chair of medical education, when asked how the University of Texas partnered with community leaders to persuade voters. “But the fact is, the community supports being healthy, and the idea to create a model healthy community with the medical school at the helm is what got people to vote yes.”

The medical school’s leaders overcame vocal opponents who said the University of Texas alone should foot the bill, not owners of city property. They also inferred spinoff economic benefits to the city from grants and investments for biotech and research.

Dr. Cox said taxpayers were receptive to the idea that “in communities with medical schools, students challenge physicians to stay up to date,” so care improvement follows.

“The medical student asks you a question that you (as teaching faculty) stumble on. ‘Why do you do it that way, Dr. Cox? What’s the evidence?’” she said. “We become better physicians because of that challenge.” Medical schools also embrace newer technology, Dr. Cox said.

The school’s advocates tout more relevant student clerkships, to meet the needs of today’s aging population, and the use of more collaborative learning methods compared with other medical schools. Dr. Cox acknowledged that Dell Med isn’t the only medical school trying to model its curriculum to fit value-based, population health–focused models of care. But it’s tougher for competing institutions to change, she said.

“Longstanding schools must eliminate something to add something new,” she noted. “And they have traditions where they’re in departments and silos, where they say, ‘We’ve always done it this way; our students do well and match in competitive residencies. We’re not going to give up any of what we’re doing.’ ”

Dell Med’s students will get a new hospital building right next door, to put their training into practice. The existing Brackenridge University Medical Center will move to a new structure scheduled to open in 2017 under a new name, the Dell Seton Medical Center at the University of Texas. The Michael and Susan Dell Foundation has pledged $50 million in support over the next 10 years.

Some big name faculty, such as former Centers for Medicare & Medicaid Services administrator and former Food and Drug Administration commissioner Mark McClellan, will join Dell Med part time. A UT-Austin alum, McClellan, who now directs Duke’s Robert J Margolis Center for Health Policy, has been a leading health reform policy analyst, influencing key federal bundled payment models now being implemented.

Another leader joining the Dell Med faculty is Dr. Christopher Moriates, coauthor of “Understanding Value-Based Healthcare,” and a series editor for JAMA Internal Medicine’s “Teachable Moments” series. In June, he will leave the University of California San Francisco, where he heads the Center for Healthcare Value’s “Caring Wisely” program, to be the assistant dean of health care value at Dell Med, “the first such title in the country,” he said.

“The goal of Dell Medical School is not to just create a new medical school, but a new type of medical school,” Dr. Moriates said. One example is a planned interdisciplinary program in orthopedics, led by Dr. Kevin Bozic, chair of surgery for Dell Medical School, that will not just teach doctors how to perform surgery for knee pain, but will explore “how do we give the best care for patients even before they get to the point of surgery? How do we keep people away from surgery?” he said.

“The idea is to look at everyone in the community who has knee pain, and focus on care that improves their health,” Dr. Moriates said, rather than just focusing on improving the efficiency of postsurgery care.

While medical students typically must wait until their third year to get hands-on clinical experience, Dell Med students will get that experience in their first year, Dr. Moriates said. During the second year, students will be in core clinical rotations, which usually doesn’t occur until the third year. Then, in the third year, medical students will focus on “innovation, leadership, and discovery,” which means inventing new ways to solve health challenges through technology and delivery system redesign.

The Dell Foundation and taxpayer support aren’t the only funding sources. The University of Texas System Board of Regents has allocated $25 million annually and another $40 million over 8 years to recruit faculty.

The investment is already generating returns. The new medical school appears to be in demand, as Dell Med received over 4,500 applications for those 50 first-year spots, Dr. Moriates said.

Dell Medical School was one of four medical schools in the United States to receive accreditation in 2015, bringing the national number of medical schools to 145, according to the accrediting body, the Liaison Committee on Medical Education. Another seven schools are listed as having applied or are candidates for accreditation.

Can a new medical school, with an unprecedented curriculum focused intensely on costs and value, employing teams that include nurses, pharmacists, and social workers, improve the health of Austin, Tex., and set a new standard for medical education?

That’s what leaders of Dell Medical School at the University of Texas at Austin promise to do, as they welcome the first class of 50 medical students in June.

The new school’s leaders convinced 55% of Travis County, Tex., voters in 2012 to pay higher property taxes to help support it. They’ll pay 5 cents more per $100 of assessed valuation, generating $54 million a year, about $35 million of which will go for the school, and for caring for underserved patients.

That’s unprecedented, said school officials. Dell Med is the only medical school in the country to receive a significant share of its funds from local property taxpayers approved by vote.

“Austin is unique. Austin is weird,” said Dr. Susan Cox, Dell Medical School’s executive vice dean of academics and chair of medical education, when asked how the University of Texas partnered with community leaders to persuade voters. “But the fact is, the community supports being healthy, and the idea to create a model healthy community with the medical school at the helm is what got people to vote yes.”

The medical school’s leaders overcame vocal opponents who said the University of Texas alone should foot the bill, not owners of city property. They also inferred spinoff economic benefits to the city from grants and investments for biotech and research.

Dr. Cox said taxpayers were receptive to the idea that “in communities with medical schools, students challenge physicians to stay up to date,” so care improvement follows.

“The medical student asks you a question that you (as teaching faculty) stumble on. ‘Why do you do it that way, Dr. Cox? What’s the evidence?’” she said. “We become better physicians because of that challenge.” Medical schools also embrace newer technology, Dr. Cox said.

The school’s advocates tout more relevant student clerkships, to meet the needs of today’s aging population, and the use of more collaborative learning methods compared with other medical schools. Dr. Cox acknowledged that Dell Med isn’t the only medical school trying to model its curriculum to fit value-based, population health–focused models of care. But it’s tougher for competing institutions to change, she said.

“Longstanding schools must eliminate something to add something new,” she noted. “And they have traditions where they’re in departments and silos, where they say, ‘We’ve always done it this way; our students do well and match in competitive residencies. We’re not going to give up any of what we’re doing.’ ”

Dell Med’s students will get a new hospital building right next door, to put their training into practice. The existing Brackenridge University Medical Center will move to a new structure scheduled to open in 2017 under a new name, the Dell Seton Medical Center at the University of Texas. The Michael and Susan Dell Foundation has pledged $50 million in support over the next 10 years.

Some big name faculty, such as former Centers for Medicare & Medicaid Services administrator and former Food and Drug Administration commissioner Mark McClellan, will join Dell Med part time. A UT-Austin alum, McClellan, who now directs Duke’s Robert J Margolis Center for Health Policy, has been a leading health reform policy analyst, influencing key federal bundled payment models now being implemented.

Another leader joining the Dell Med faculty is Dr. Christopher Moriates, coauthor of “Understanding Value-Based Healthcare,” and a series editor for JAMA Internal Medicine’s “Teachable Moments” series. In June, he will leave the University of California San Francisco, where he heads the Center for Healthcare Value’s “Caring Wisely” program, to be the assistant dean of health care value at Dell Med, “the first such title in the country,” he said.

“The goal of Dell Medical School is not to just create a new medical school, but a new type of medical school,” Dr. Moriates said. One example is a planned interdisciplinary program in orthopedics, led by Dr. Kevin Bozic, chair of surgery for Dell Medical School, that will not just teach doctors how to perform surgery for knee pain, but will explore “how do we give the best care for patients even before they get to the point of surgery? How do we keep people away from surgery?” he said.

“The idea is to look at everyone in the community who has knee pain, and focus on care that improves their health,” Dr. Moriates said, rather than just focusing on improving the efficiency of postsurgery care.

While medical students typically must wait until their third year to get hands-on clinical experience, Dell Med students will get that experience in their first year, Dr. Moriates said. During the second year, students will be in core clinical rotations, which usually doesn’t occur until the third year. Then, in the third year, medical students will focus on “innovation, leadership, and discovery,” which means inventing new ways to solve health challenges through technology and delivery system redesign.

The Dell Foundation and taxpayer support aren’t the only funding sources. The University of Texas System Board of Regents has allocated $25 million annually and another $40 million over 8 years to recruit faculty.

The investment is already generating returns. The new medical school appears to be in demand, as Dell Med received over 4,500 applications for those 50 first-year spots, Dr. Moriates said.

Dell Medical School was one of four medical schools in the United States to receive accreditation in 2015, bringing the national number of medical schools to 145, according to the accrediting body, the Liaison Committee on Medical Education. Another seven schools are listed as having applied or are candidates for accreditation.

Can a new medical school, with an unprecedented curriculum focused intensely on costs and value, employing teams that include nurses, pharmacists, and social workers, improve the health of Austin, Tex., and set a new standard for medical education?

That’s what leaders of Dell Medical School at the University of Texas at Austin promise to do, as they welcome the first class of 50 medical students in June.

The new school’s leaders convinced 55% of Travis County, Tex., voters in 2012 to pay higher property taxes to help support it. They’ll pay 5 cents more per $100 of assessed valuation, generating $54 million a year, about $35 million of which will go for the school, and for caring for underserved patients.

That’s unprecedented, said school officials. Dell Med is the only medical school in the country to receive a significant share of its funds from local property taxpayers approved by vote.

“Austin is unique. Austin is weird,” said Dr. Susan Cox, Dell Medical School’s executive vice dean of academics and chair of medical education, when asked how the University of Texas partnered with community leaders to persuade voters. “But the fact is, the community supports being healthy, and the idea to create a model healthy community with the medical school at the helm is what got people to vote yes.”

The medical school’s leaders overcame vocal opponents who said the University of Texas alone should foot the bill, not owners of city property. They also inferred spinoff economic benefits to the city from grants and investments for biotech and research.

Dr. Cox said taxpayers were receptive to the idea that “in communities with medical schools, students challenge physicians to stay up to date,” so care improvement follows.

“The medical student asks you a question that you (as teaching faculty) stumble on. ‘Why do you do it that way, Dr. Cox? What’s the evidence?’” she said. “We become better physicians because of that challenge.” Medical schools also embrace newer technology, Dr. Cox said.

The school’s advocates tout more relevant student clerkships, to meet the needs of today’s aging population, and the use of more collaborative learning methods compared with other medical schools. Dr. Cox acknowledged that Dell Med isn’t the only medical school trying to model its curriculum to fit value-based, population health–focused models of care. But it’s tougher for competing institutions to change, she said.

“Longstanding schools must eliminate something to add something new,” she noted. “And they have traditions where they’re in departments and silos, where they say, ‘We’ve always done it this way; our students do well and match in competitive residencies. We’re not going to give up any of what we’re doing.’ ”

Dell Med’s students will get a new hospital building right next door, to put their training into practice. The existing Brackenridge University Medical Center will move to a new structure scheduled to open in 2017 under a new name, the Dell Seton Medical Center at the University of Texas. The Michael and Susan Dell Foundation has pledged $50 million in support over the next 10 years.

Some big name faculty, such as former Centers for Medicare & Medicaid Services administrator and former Food and Drug Administration commissioner Mark McClellan, will join Dell Med part time. A UT-Austin alum, McClellan, who now directs Duke’s Robert J Margolis Center for Health Policy, has been a leading health reform policy analyst, influencing key federal bundled payment models now being implemented.

Another leader joining the Dell Med faculty is Dr. Christopher Moriates, coauthor of “Understanding Value-Based Healthcare,” and a series editor for JAMA Internal Medicine’s “Teachable Moments” series. In June, he will leave the University of California San Francisco, where he heads the Center for Healthcare Value’s “Caring Wisely” program, to be the assistant dean of health care value at Dell Med, “the first such title in the country,” he said.

“The goal of Dell Medical School is not to just create a new medical school, but a new type of medical school,” Dr. Moriates said. One example is a planned interdisciplinary program in orthopedics, led by Dr. Kevin Bozic, chair of surgery for Dell Medical School, that will not just teach doctors how to perform surgery for knee pain, but will explore “how do we give the best care for patients even before they get to the point of surgery? How do we keep people away from surgery?” he said.

“The idea is to look at everyone in the community who has knee pain, and focus on care that improves their health,” Dr. Moriates said, rather than just focusing on improving the efficiency of postsurgery care.

While medical students typically must wait until their third year to get hands-on clinical experience, Dell Med students will get that experience in their first year, Dr. Moriates said. During the second year, students will be in core clinical rotations, which usually doesn’t occur until the third year. Then, in the third year, medical students will focus on “innovation, leadership, and discovery,” which means inventing new ways to solve health challenges through technology and delivery system redesign.

The Dell Foundation and taxpayer support aren’t the only funding sources. The University of Texas System Board of Regents has allocated $25 million annually and another $40 million over 8 years to recruit faculty.

The investment is already generating returns. The new medical school appears to be in demand, as Dell Med received over 4,500 applications for those 50 first-year spots, Dr. Moriates said.

Dell Medical School was one of four medical schools in the United States to receive accreditation in 2015, bringing the national number of medical schools to 145, according to the accrediting body, the Liaison Committee on Medical Education. Another seven schools are listed as having applied or are candidates for accreditation.

SAN DIEGO – Hospitalists have a lot to learn about providing care for the growing number of their patients addicted to opioids.

“By and large, we’re just addressing the medical problems that brought them in,” said Dr. Jesse Theisen-Toupal, an addiction researcher and hospitalist at the Veterans Affairs Medical Center in Washington, D.C. “But whether it’s because of our lack of education, or lack of adequate resources in hospitals, we’re not really [treating] their addiction.”

That’s a real problem that can cause addicted patients harm, and may bring them right back into the hospital.

Dr. Theisen-Toupal, who treated many patients with addiction over the 6-year period when he was a resident and attending physician at Beth Israel Deaconess Medical Center in Boston, discussed these concerns at the Society of Hospital Medicine annual meeting, and in a follow-up phone interview.

While President Obama’s recently announced $1.1 billion program to improve access to treatment for addiction will help, as will lifting the ban on the use of federal funds for syringe exchange programs, those efforts are largely aimed at managing outpatients.

“They may not change the way hospitalists manage an admitted patient with opioid addiction,” Dr. Theisen-Toupal said. “Hospitalists have access to a group of people who are not plugged into outpatient providers, and have a great opportunity to engage them into treatment.” Hospitalists must do much more for these patients than they currently are, he noted, in four key areas.

Pain Management

First, hospitalists must do a better job treating the pain that sometimes comes with an acute medical problem, like appendicitis or infective endocarditis. “We still need to treat them humanely,” Dr. Theisen-Toupal said. “But we’re very hesitant to give into somebody’s addiction, so we often don’t give appropriate doses [of pain medication].”

Better care may mean giving drug-addicted patients higher doses than nonaddicted patients who have lower tolerance thresholds, so long as physicians give the lowest amount that’s adequate for the shortest duration. “And if you can get away with it, use Tylenol or NSAIDs,” Dr. Theisen-Toupal said. “Just treat the pain.”

Withdrawal

Second, hospitalists often overlook the fact that opioid-using patients may go into withdrawal during their stay, a condition the hospitalist should be treating simultaneously.

“The classic teaching is that you can’t die from opioid withdrawal, but you can be really, really miserable,” Dr. Theisen-Toupal said. Without withdrawal treatment, the patient is forced to decide whether to leave the hospital to find and take more drugs, foregoing needed medical care, “or to suffer through the hospital stay.” Many choose the first option.

Thoughtful doses of methadone, buprenorphine, or clonidine can “take that hard decision off the table,” he said. Currently, common practice is to treat obvious symptoms piecemeal, for example, treating diarrhea with an antimotility agent, but that’s not effective at managing withdrawal.

Dr. Theisen-Toupal said detox and treatment centers treat withdrawal, but that knowledge “hasn’t necessarily made its way to the internal medicine and hospitalist community,” nor is it usually part of medical education.

Outpatient Referrals

Third, hospitalists should help connect addicted patients with appropriate outpatient specialists in substance abuse/disorder. “We need to create these connections,” Dr. Theisen-Toupal said. Referral discussions “only take a minute or two.”

Harm Reduction

Fourth, hospitalists must teach addicted patients harm-reduction strategies, such as safer injection practices that won’t bring them back to the hospital. This is “a real opportunity to prevent future harm,” Dr. Theisen-Toupal said.

For example, one-third of injection drug users “will lick the needle before they inject. That’s terrible because there’s bacteria and other nonsterile things in the mouth that they’re then injecting into the body,” leading to infections, he said. He’s also had patients who used roadside puddle water or toilet bowl water to dissolve heroin.

Harm-reduction education “can be just a 2-minute intervention, but it can have a big future payoff to prevent serious infections,” he said.

One easy harm-reduction strategy is to prophylactically prescribe naloxone, which reduces respiratory depression and sedation, in case of an overdose after discharge, and works much like an EpiPen. Dr. Theisen-Toupal said the hospitalist can make sure the patient’s family and friends know how to recognize an overdose and promptly use naloxone correctly. They should then be taught to “call EMS immediately, begin rescue breathing or CPR, and administer naloxone, and stay with the patient until they arrive.”

Dr. Theisen-Toupal acknowledged that some critics argue such policies could encourage drug use. “That is an argument, but when you look at some of the studies, it doesn’t hold much water,” he said. One such study , published in the British Medical Journal in 2013, compared areas with no naloxone education or distribution, some education or distribution, and an extensive amount of education or distribution. In the latter, he said, “there was actually a reduction in the opioid overdose death rate of 46%,” compared with the area that had no naloxone intervention.

Dr. Theisen-Toupal emphasized that with more than 28,600 opioid-related U.S. deaths in 2014, hospitalists must dispense with judgmental attitudes pervasive in many hospitals. Addiction “is not a counterculture thing anymore, on the margins of society,” he said. “Now, it’s senators’ kids and judges’ kids and middle class families’ kids. It’s everywhere, and it has to be addressed.”

Ultimately, hospitalists should reframe opioid addiction not as a social problem “or moral weakness,” but as a medical issue.

Dr. Theisen-Toupal said he had no relevant financial disclosures.

SAN DIEGO – Hospitalists have a lot to learn about providing care for the growing number of their patients addicted to opioids.

“By and large, we’re just addressing the medical problems that brought them in,” said Dr. Jesse Theisen-Toupal, an addiction researcher and hospitalist at the Veterans Affairs Medical Center in Washington, D.C. “But whether it’s because of our lack of education, or lack of adequate resources in hospitals, we’re not really [treating] their addiction.”

That’s a real problem that can cause addicted patients harm, and may bring them right back into the hospital.

Dr. Theisen-Toupal, who treated many patients with addiction over the 6-year period when he was a resident and attending physician at Beth Israel Deaconess Medical Center in Boston, discussed these concerns at the Society of Hospital Medicine annual meeting, and in a follow-up phone interview.

While President Obama’s recently announced $1.1 billion program to improve access to treatment for addiction will help, as will lifting the ban on the use of federal funds for syringe exchange programs, those efforts are largely aimed at managing outpatients.

“They may not change the way hospitalists manage an admitted patient with opioid addiction,” Dr. Theisen-Toupal said. “Hospitalists have access to a group of people who are not plugged into outpatient providers, and have a great opportunity to engage them into treatment.” Hospitalists must do much more for these patients than they currently are, he noted, in four key areas.

Pain Management

First, hospitalists must do a better job treating the pain that sometimes comes with an acute medical problem, like appendicitis or infective endocarditis. “We still need to treat them humanely,” Dr. Theisen-Toupal said. “But we’re very hesitant to give into somebody’s addiction, so we often don’t give appropriate doses [of pain medication].”

Better care may mean giving drug-addicted patients higher doses than nonaddicted patients who have lower tolerance thresholds, so long as physicians give the lowest amount that’s adequate for the shortest duration. “And if you can get away with it, use Tylenol or NSAIDs,” Dr. Theisen-Toupal said. “Just treat the pain.”

Withdrawal

Second, hospitalists often overlook the fact that opioid-using patients may go into withdrawal during their stay, a condition the hospitalist should be treating simultaneously.

“The classic teaching is that you can’t die from opioid withdrawal, but you can be really, really miserable,” Dr. Theisen-Toupal said. Without withdrawal treatment, the patient is forced to decide whether to leave the hospital to find and take more drugs, foregoing needed medical care, “or to suffer through the hospital stay.” Many choose the first option.

Thoughtful doses of methadone, buprenorphine, or clonidine can “take that hard decision off the table,” he said. Currently, common practice is to treat obvious symptoms piecemeal, for example, treating diarrhea with an antimotility agent, but that’s not effective at managing withdrawal.

Dr. Theisen-Toupal said detox and treatment centers treat withdrawal, but that knowledge “hasn’t necessarily made its way to the internal medicine and hospitalist community,” nor is it usually part of medical education.

Outpatient Referrals

Third, hospitalists should help connect addicted patients with appropriate outpatient specialists in substance abuse/disorder. “We need to create these connections,” Dr. Theisen-Toupal said. Referral discussions “only take a minute or two.”

Harm Reduction

Fourth, hospitalists must teach addicted patients harm-reduction strategies, such as safer injection practices that won’t bring them back to the hospital. This is “a real opportunity to prevent future harm,” Dr. Theisen-Toupal said.

For example, one-third of injection drug users “will lick the needle before they inject. That’s terrible because there’s bacteria and other nonsterile things in the mouth that they’re then injecting into the body,” leading to infections, he said. He’s also had patients who used roadside puddle water or toilet bowl water to dissolve heroin.

Harm-reduction education “can be just a 2-minute intervention, but it can have a big future payoff to prevent serious infections,” he said.

One easy harm-reduction strategy is to prophylactically prescribe naloxone, which reduces respiratory depression and sedation, in case of an overdose after discharge, and works much like an EpiPen. Dr. Theisen-Toupal said the hospitalist can make sure the patient’s family and friends know how to recognize an overdose and promptly use naloxone correctly. They should then be taught to “call EMS immediately, begin rescue breathing or CPR, and administer naloxone, and stay with the patient until they arrive.”

Dr. Theisen-Toupal acknowledged that some critics argue such policies could encourage drug use. “That is an argument, but when you look at some of the studies, it doesn’t hold much water,” he said. One such study , published in the British Medical Journal in 2013, compared areas with no naloxone education or distribution, some education or distribution, and an extensive amount of education or distribution. In the latter, he said, “there was actually a reduction in the opioid overdose death rate of 46%,” compared with the area that had no naloxone intervention.

Dr. Theisen-Toupal emphasized that with more than 28,600 opioid-related U.S. deaths in 2014, hospitalists must dispense with judgmental attitudes pervasive in many hospitals. Addiction “is not a counterculture thing anymore, on the margins of society,” he said. “Now, it’s senators’ kids and judges’ kids and middle class families’ kids. It’s everywhere, and it has to be addressed.”

Ultimately, hospitalists should reframe opioid addiction not as a social problem “or moral weakness,” but as a medical issue.

Dr. Theisen-Toupal said he had no relevant financial disclosures.

SAN DIEGO – Hospitalists have a lot to learn about providing care for the growing number of their patients addicted to opioids.

“By and large, we’re just addressing the medical problems that brought them in,” said Dr. Jesse Theisen-Toupal, an addiction researcher and hospitalist at the Veterans Affairs Medical Center in Washington, D.C. “But whether it’s because of our lack of education, or lack of adequate resources in hospitals, we’re not really [treating] their addiction.”

That’s a real problem that can cause addicted patients harm, and may bring them right back into the hospital.

Dr. Theisen-Toupal, who treated many patients with addiction over the 6-year period when he was a resident and attending physician at Beth Israel Deaconess Medical Center in Boston, discussed these concerns at the Society of Hospital Medicine annual meeting, and in a follow-up phone interview.

While President Obama’s recently announced $1.1 billion program to improve access to treatment for addiction will help, as will lifting the ban on the use of federal funds for syringe exchange programs, those efforts are largely aimed at managing outpatients.

“They may not change the way hospitalists manage an admitted patient with opioid addiction,” Dr. Theisen-Toupal said. “Hospitalists have access to a group of people who are not plugged into outpatient providers, and have a great opportunity to engage them into treatment.” Hospitalists must do much more for these patients than they currently are, he noted, in four key areas.

Pain Management

First, hospitalists must do a better job treating the pain that sometimes comes with an acute medical problem, like appendicitis or infective endocarditis. “We still need to treat them humanely,” Dr. Theisen-Toupal said. “But we’re very hesitant to give into somebody’s addiction, so we often don’t give appropriate doses [of pain medication].”

Better care may mean giving drug-addicted patients higher doses than nonaddicted patients who have lower tolerance thresholds, so long as physicians give the lowest amount that’s adequate for the shortest duration. “And if you can get away with it, use Tylenol or NSAIDs,” Dr. Theisen-Toupal said. “Just treat the pain.”

Withdrawal

Second, hospitalists often overlook the fact that opioid-using patients may go into withdrawal during their stay, a condition the hospitalist should be treating simultaneously.

“The classic teaching is that you can’t die from opioid withdrawal, but you can be really, really miserable,” Dr. Theisen-Toupal said. Without withdrawal treatment, the patient is forced to decide whether to leave the hospital to find and take more drugs, foregoing needed medical care, “or to suffer through the hospital stay.” Many choose the first option.

Thoughtful doses of methadone, buprenorphine, or clonidine can “take that hard decision off the table,” he said. Currently, common practice is to treat obvious symptoms piecemeal, for example, treating diarrhea with an antimotility agent, but that’s not effective at managing withdrawal.

Dr. Theisen-Toupal said detox and treatment centers treat withdrawal, but that knowledge “hasn’t necessarily made its way to the internal medicine and hospitalist community,” nor is it usually part of medical education.

Outpatient Referrals

Third, hospitalists should help connect addicted patients with appropriate outpatient specialists in substance abuse/disorder. “We need to create these connections,” Dr. Theisen-Toupal said. Referral discussions “only take a minute or two.”

Harm Reduction

Fourth, hospitalists must teach addicted patients harm-reduction strategies, such as safer injection practices that won’t bring them back to the hospital. This is “a real opportunity to prevent future harm,” Dr. Theisen-Toupal said.

For example, one-third of injection drug users “will lick the needle before they inject. That’s terrible because there’s bacteria and other nonsterile things in the mouth that they’re then injecting into the body,” leading to infections, he said. He’s also had patients who used roadside puddle water or toilet bowl water to dissolve heroin.

Harm-reduction education “can be just a 2-minute intervention, but it can have a big future payoff to prevent serious infections,” he said.

One easy harm-reduction strategy is to prophylactically prescribe naloxone, which reduces respiratory depression and sedation, in case of an overdose after discharge, and works much like an EpiPen. Dr. Theisen-Toupal said the hospitalist can make sure the patient’s family and friends know how to recognize an overdose and promptly use naloxone correctly. They should then be taught to “call EMS immediately, begin rescue breathing or CPR, and administer naloxone, and stay with the patient until they arrive.”

Dr. Theisen-Toupal acknowledged that some critics argue such policies could encourage drug use. “That is an argument, but when you look at some of the studies, it doesn’t hold much water,” he said. One such study , published in the British Medical Journal in 2013, compared areas with no naloxone education or distribution, some education or distribution, and an extensive amount of education or distribution. In the latter, he said, “there was actually a reduction in the opioid overdose death rate of 46%,” compared with the area that had no naloxone intervention.

Dr. Theisen-Toupal emphasized that with more than 28,600 opioid-related U.S. deaths in 2014, hospitalists must dispense with judgmental attitudes pervasive in many hospitals. Addiction “is not a counterculture thing anymore, on the margins of society,” he said. “Now, it’s senators’ kids and judges’ kids and middle class families’ kids. It’s everywhere, and it has to be addressed.”

Ultimately, hospitalists should reframe opioid addiction not as a social problem “or moral weakness,” but as a medical issue.

Dr. Theisen-Toupal said he had no relevant financial disclosures.

SAN DIEGO – Hospitalists looking for ways to reduce costs and make their patients safer might learn strategies from the TV game show “Shark Tank.”

Shark Tank is a reality television show in which aspiring entrepreneurs make business presentations to a panel of “shark” investors, who then choose whether or not to invest. During a session at the annual meeting of the Society of Hospital Medicine, entrepreneurial hospitalists did something similar. They divided themselves into five teams that had 20 minutes to pitch a bright idea to avoid unnecessary care, even if it meant overcoming long traditions and resistance from powerful leadership.

The hospitalist “contestants” faced three “sharks” – all veteran “cost of care–conscious” hospitalists – who each had $100,000 in fake dollars to invest. The sharks emphasized that the idea behind the game was to incentivize hospitalists to think creatively, outside of their routines.

Dr. Christopher Moriates, director of the University of California, San Francisco, Caring Wisely program and of implementation initiatives at Costs of Care, a leader of the session, did not expect that all the “entrepreneurial” ideas presented would work in every setting, but some were likely to be useful as ways to examine hospitalist routines that no longer really make sense. For instance, Dr. Moriates said that, during his residency, “a ritual I wrapped myself in … like stirring milk into my coffee … was, in the morning I’d make my list, I’d look at peoples’ labs, and replete the potassium like a ninja,” whether it was needed or not.

Dr. Moriates noted that the “Think Twice, Stick Once” program at UCSF to reduce unnecessary phlebotomy draws is one example hospitalist “entrepreneurs” could model. When it was proposed, “It made a lot of doctors in our hospital uncomfortable,” he said. “Most of our colleagues did not really care about saving a CBC. But they did care about their patients, so when we reframed the idea as ‘sticking your patients, the 4 a.m. phlebotomist waking you up,’ that seemed to resonate more.”

Dr. Vineet Arora, director of GME Clinical Learning Environment Innovation at the University of Chicago and educational initiatives at Costs of Care, one of the three “sharks,” said the entrepreneurial teams’ ideas should include processes that are sustainable across nurses and doctors. Can clinicians “walk into a room and see, ‘Oh that Foley is not indicated?’ “ Dr. Arora asked. “It turns out that stopping something is a lot harder than starting something … so you need to train people to think, ‘How do I figure out what to stop.’”

The two other “sharks” were Dr. Reshma Gupta, director of the joint Costs of Care/American Board of Internal Medicine Foundation Teaching Value in Healthcare Learning Network, and September Wallingford, director of operations for Costs of Care and a registered nurse at Brigham & Women’s Hospital in Boston.

In the tank

First up in the conference competition were the “Cheetahs,” led by Dr. Mohamed Morad, a hospitalist at Ball Memorial Hospital in Muncie, Ind. His team said patients are often put on telemetry without indication, and stricter guidelines would reduce that overutilization. “A lot of physicians are not aware or they’re not following guidelines,” he said, and nurses “don’t have a say in deciding who should be on telemetry or not.”

During an interview, Dr. Morad noted telemetry is important for patients suspected of stroke or transient ischemic attack, or who have cardiovascular risks. But others get telemetry unnecessarily. That adds significant costs, ranging from around $400 per patient, but telemetry increases alarms, and thus alarm fatigue. “You have to ask, is it doing a good job, or causing a lot of distraction and not really helping the patient?” Dr. Morad said.

Out of the $300,000 the sharks had to distribute, the Cheetahs received $55,000.

The Top Values team, led by hospitalist Dr. Jason Meadows, assistant attending at Memorial Sloan-Kettering Cancer Center in New York, proposed “X to the O₂,” to reduce the number of patients on oxygen. “There’s a lot of evidence showing toxicity with high levels,” Dr. Meadows said. “And patients who are tethered (with a cannula) can have an increase in delirium and falls.”

The Top Values proposed stricter protocols to reduce automatic oxygen “and daily monitoring to make sure the patients still need it.”

“I love this idea,” said “shark” Dr. Arora. “I see this a lot on rounds. … Often on the day of discharge I ask how come this patient is on oxygen? I think there’s a reflex here … to have patients on oxygen even when it’s not ordered.” The Top Values team received $60,000.

The third team, “Value Attack,” named their pitch “Push to the PO,” to reduce unnecessary administration of IV antibiotics when cheaper, safer oral dosage works equally well, said Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Often, Dr. Moore explained, ED patients are put on an IV if an infection is suspected. “Then they come up to the floor, and the patent stays on IV antibiotics longer than they need it,” even after infection is ruled out.

IV administration has drawbacks. First it’s expensive, she said. “Levaquin IV is $15, but p.o. is $3. PPI [proton pump inhibitor] is $144 IV but $4 p.o.” And there are other problems such as patients’ pain, having multiple IVs, more nursing care, and more time administering the IV.

The Value Attack’s pitch included enlisting speech and swallowing experts to advise when oral antibiotic doses can substitute. Their idea generated $50,000.

Another team, the “Invaluables,” proposed “Just in time discharge” which would use night hospitalists to discharge patients in the evening, if they’re ready to go home and a ride is available, instead of waiting until morning. Dr. Peter Kaboli, chief of medicine at Iowa City VA Medical Center, said at his hospital, as many as 2 patients of up to 12 discharged a day might be able to go home 15 hours earlier, alleviating boarding in the ED for patients who otherwise wait overnight.

“Our culture is that patients don’t leave after 6 p.m.,” even if they’re ready to go, and a ride is ready, Dr. Kaboli said. He acknowledged the concept is not yet based on evidence, “so we’re kind of sticking our necks out here, but nothing ventured, nothing gained.” The team proposed testing discharges by night shift hospitalists. Their idea was awarded $50,000 by the sharks.

The winning Shark Tank team was the Cost Cutters, who proposed “Standup to Syncope” as their project. Dr. Celene Goetz, a hospitalist at Mount Sinai Medical Center in New York, said all too often, healthy nontrauma patients come into the ED because they fainted, usually because they were dehydrated and called 911, and receive a costly head CT scan and unnecessary radiation exposure.

For many of these patients, taking orthostatic vital signs would rule out CT and reduce admissions, not to mention time in the ED. The problem, she explained in an interview, is that ED physicians don’t do the orthostatic, which requires 5 minutes or more of monitoring the patient’s blood pressure.

“That takes so much of a practitioner’s time, and it’s just easier to order the head CT and put a patient on telemetry,” Dr. Goetz said, noting that ED physicians are often worried about lawsuits from missing a stroke or intracranial hemorrhage.

In a poster presented at the conference, Dr. Goetz reported on 162 patients presenting to the ED with syncope. Of these, 71, or 43.6%, got a head CT, and half of these were inappropriate according to American College of Emergency Physicians’ recommendations. Additionally, “none of the head CTs identified an intracranial bleed or changed management.” Further, “if inappropriate head CTs were not ordered for this group of patients, the hospital could have saved at least $8,680 per year,” Dr. Goetz said.

The “sharks” said this was the best idea, and awarded the winning Cost Cutters $70,000.

[email protected]

SAN DIEGO – Hospitalists looking for ways to reduce costs and make their patients safer might learn strategies from the TV game show “Shark Tank.”

Shark Tank is a reality television show in which aspiring entrepreneurs make business presentations to a panel of “shark” investors, who then choose whether or not to invest. During a session at the annual meeting of the Society of Hospital Medicine, entrepreneurial hospitalists did something similar. They divided themselves into five teams that had 20 minutes to pitch a bright idea to avoid unnecessary care, even if it meant overcoming long traditions and resistance from powerful leadership.

The hospitalist “contestants” faced three “sharks” – all veteran “cost of care–conscious” hospitalists – who each had $100,000 in fake dollars to invest. The sharks emphasized that the idea behind the game was to incentivize hospitalists to think creatively, outside of their routines.

Dr. Christopher Moriates, director of the University of California, San Francisco, Caring Wisely program and of implementation initiatives at Costs of Care, a leader of the session, did not expect that all the “entrepreneurial” ideas presented would work in every setting, but some were likely to be useful as ways to examine hospitalist routines that no longer really make sense. For instance, Dr. Moriates said that, during his residency, “a ritual I wrapped myself in … like stirring milk into my coffee … was, in the morning I’d make my list, I’d look at peoples’ labs, and replete the potassium like a ninja,” whether it was needed or not.

Dr. Moriates noted that the “Think Twice, Stick Once” program at UCSF to reduce unnecessary phlebotomy draws is one example hospitalist “entrepreneurs” could model. When it was proposed, “It made a lot of doctors in our hospital uncomfortable,” he said. “Most of our colleagues did not really care about saving a CBC. But they did care about their patients, so when we reframed the idea as ‘sticking your patients, the 4 a.m. phlebotomist waking you up,’ that seemed to resonate more.”

Dr. Vineet Arora, director of GME Clinical Learning Environment Innovation at the University of Chicago and educational initiatives at Costs of Care, one of the three “sharks,” said the entrepreneurial teams’ ideas should include processes that are sustainable across nurses and doctors. Can clinicians “walk into a room and see, ‘Oh that Foley is not indicated?’ “ Dr. Arora asked. “It turns out that stopping something is a lot harder than starting something … so you need to train people to think, ‘How do I figure out what to stop.’”

The two other “sharks” were Dr. Reshma Gupta, director of the joint Costs of Care/American Board of Internal Medicine Foundation Teaching Value in Healthcare Learning Network, and September Wallingford, director of operations for Costs of Care and a registered nurse at Brigham & Women’s Hospital in Boston.

In the tank

First up in the conference competition were the “Cheetahs,” led by Dr. Mohamed Morad, a hospitalist at Ball Memorial Hospital in Muncie, Ind. His team said patients are often put on telemetry without indication, and stricter guidelines would reduce that overutilization. “A lot of physicians are not aware or they’re not following guidelines,” he said, and nurses “don’t have a say in deciding who should be on telemetry or not.”

During an interview, Dr. Morad noted telemetry is important for patients suspected of stroke or transient ischemic attack, or who have cardiovascular risks. But others get telemetry unnecessarily. That adds significant costs, ranging from around $400 per patient, but telemetry increases alarms, and thus alarm fatigue. “You have to ask, is it doing a good job, or causing a lot of distraction and not really helping the patient?” Dr. Morad said.

Out of the $300,000 the sharks had to distribute, the Cheetahs received $55,000.

The Top Values team, led by hospitalist Dr. Jason Meadows, assistant attending at Memorial Sloan-Kettering Cancer Center in New York, proposed “X to the O₂,” to reduce the number of patients on oxygen. “There’s a lot of evidence showing toxicity with high levels,” Dr. Meadows said. “And patients who are tethered (with a cannula) can have an increase in delirium and falls.”

The Top Values proposed stricter protocols to reduce automatic oxygen “and daily monitoring to make sure the patients still need it.”

“I love this idea,” said “shark” Dr. Arora. “I see this a lot on rounds. … Often on the day of discharge I ask how come this patient is on oxygen? I think there’s a reflex here … to have patients on oxygen even when it’s not ordered.” The Top Values team received $60,000.

The third team, “Value Attack,” named their pitch “Push to the PO,” to reduce unnecessary administration of IV antibiotics when cheaper, safer oral dosage works equally well, said Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Often, Dr. Moore explained, ED patients are put on an IV if an infection is suspected. “Then they come up to the floor, and the patent stays on IV antibiotics longer than they need it,” even after infection is ruled out.

IV administration has drawbacks. First it’s expensive, she said. “Levaquin IV is $15, but p.o. is $3. PPI [proton pump inhibitor] is $144 IV but $4 p.o.” And there are other problems such as patients’ pain, having multiple IVs, more nursing care, and more time administering the IV.

The Value Attack’s pitch included enlisting speech and swallowing experts to advise when oral antibiotic doses can substitute. Their idea generated $50,000.

Another team, the “Invaluables,” proposed “Just in time discharge” which would use night hospitalists to discharge patients in the evening, if they’re ready to go home and a ride is available, instead of waiting until morning. Dr. Peter Kaboli, chief of medicine at Iowa City VA Medical Center, said at his hospital, as many as 2 patients of up to 12 discharged a day might be able to go home 15 hours earlier, alleviating boarding in the ED for patients who otherwise wait overnight.

“Our culture is that patients don’t leave after 6 p.m.,” even if they’re ready to go, and a ride is ready, Dr. Kaboli said. He acknowledged the concept is not yet based on evidence, “so we’re kind of sticking our necks out here, but nothing ventured, nothing gained.” The team proposed testing discharges by night shift hospitalists. Their idea was awarded $50,000 by the sharks.

The winning Shark Tank team was the Cost Cutters, who proposed “Standup to Syncope” as their project. Dr. Celene Goetz, a hospitalist at Mount Sinai Medical Center in New York, said all too often, healthy nontrauma patients come into the ED because they fainted, usually because they were dehydrated and called 911, and receive a costly head CT scan and unnecessary radiation exposure.

For many of these patients, taking orthostatic vital signs would rule out CT and reduce admissions, not to mention time in the ED. The problem, she explained in an interview, is that ED physicians don’t do the orthostatic, which requires 5 minutes or more of monitoring the patient’s blood pressure.

“That takes so much of a practitioner’s time, and it’s just easier to order the head CT and put a patient on telemetry,” Dr. Goetz said, noting that ED physicians are often worried about lawsuits from missing a stroke or intracranial hemorrhage.

In a poster presented at the conference, Dr. Goetz reported on 162 patients presenting to the ED with syncope. Of these, 71, or 43.6%, got a head CT, and half of these were inappropriate according to American College of Emergency Physicians’ recommendations. Additionally, “none of the head CTs identified an intracranial bleed or changed management.” Further, “if inappropriate head CTs were not ordered for this group of patients, the hospital could have saved at least $8,680 per year,” Dr. Goetz said.

The “sharks” said this was the best idea, and awarded the winning Cost Cutters $70,000.

[email protected]

SAN DIEGO – Hospitalists looking for ways to reduce costs and make their patients safer might learn strategies from the TV game show “Shark Tank.”

Shark Tank is a reality television show in which aspiring entrepreneurs make business presentations to a panel of “shark” investors, who then choose whether or not to invest. During a session at the annual meeting of the Society of Hospital Medicine, entrepreneurial hospitalists did something similar. They divided themselves into five teams that had 20 minutes to pitch a bright idea to avoid unnecessary care, even if it meant overcoming long traditions and resistance from powerful leadership.

The hospitalist “contestants” faced three “sharks” – all veteran “cost of care–conscious” hospitalists – who each had $100,000 in fake dollars to invest. The sharks emphasized that the idea behind the game was to incentivize hospitalists to think creatively, outside of their routines.

Dr. Christopher Moriates, director of the University of California, San Francisco, Caring Wisely program and of implementation initiatives at Costs of Care, a leader of the session, did not expect that all the “entrepreneurial” ideas presented would work in every setting, but some were likely to be useful as ways to examine hospitalist routines that no longer really make sense. For instance, Dr. Moriates said that, during his residency, “a ritual I wrapped myself in … like stirring milk into my coffee … was, in the morning I’d make my list, I’d look at peoples’ labs, and replete the potassium like a ninja,” whether it was needed or not.

Dr. Moriates noted that the “Think Twice, Stick Once” program at UCSF to reduce unnecessary phlebotomy draws is one example hospitalist “entrepreneurs” could model. When it was proposed, “It made a lot of doctors in our hospital uncomfortable,” he said. “Most of our colleagues did not really care about saving a CBC. But they did care about their patients, so when we reframed the idea as ‘sticking your patients, the 4 a.m. phlebotomist waking you up,’ that seemed to resonate more.”

Dr. Vineet Arora, director of GME Clinical Learning Environment Innovation at the University of Chicago and educational initiatives at Costs of Care, one of the three “sharks,” said the entrepreneurial teams’ ideas should include processes that are sustainable across nurses and doctors. Can clinicians “walk into a room and see, ‘Oh that Foley is not indicated?’ “ Dr. Arora asked. “It turns out that stopping something is a lot harder than starting something … so you need to train people to think, ‘How do I figure out what to stop.’”

The two other “sharks” were Dr. Reshma Gupta, director of the joint Costs of Care/American Board of Internal Medicine Foundation Teaching Value in Healthcare Learning Network, and September Wallingford, director of operations for Costs of Care and a registered nurse at Brigham & Women’s Hospital in Boston.

In the tank

First up in the conference competition were the “Cheetahs,” led by Dr. Mohamed Morad, a hospitalist at Ball Memorial Hospital in Muncie, Ind. His team said patients are often put on telemetry without indication, and stricter guidelines would reduce that overutilization. “A lot of physicians are not aware or they’re not following guidelines,” he said, and nurses “don’t have a say in deciding who should be on telemetry or not.”

During an interview, Dr. Morad noted telemetry is important for patients suspected of stroke or transient ischemic attack, or who have cardiovascular risks. But others get telemetry unnecessarily. That adds significant costs, ranging from around $400 per patient, but telemetry increases alarms, and thus alarm fatigue. “You have to ask, is it doing a good job, or causing a lot of distraction and not really helping the patient?” Dr. Morad said.

Out of the $300,000 the sharks had to distribute, the Cheetahs received $55,000.

The Top Values team, led by hospitalist Dr. Jason Meadows, assistant attending at Memorial Sloan-Kettering Cancer Center in New York, proposed “X to the O₂,” to reduce the number of patients on oxygen. “There’s a lot of evidence showing toxicity with high levels,” Dr. Meadows said. “And patients who are tethered (with a cannula) can have an increase in delirium and falls.”

The Top Values proposed stricter protocols to reduce automatic oxygen “and daily monitoring to make sure the patients still need it.”

“I love this idea,” said “shark” Dr. Arora. “I see this a lot on rounds. … Often on the day of discharge I ask how come this patient is on oxygen? I think there’s a reflex here … to have patients on oxygen even when it’s not ordered.” The Top Values team received $60,000.

The third team, “Value Attack,” named their pitch “Push to the PO,” to reduce unnecessary administration of IV antibiotics when cheaper, safer oral dosage works equally well, said Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Often, Dr. Moore explained, ED patients are put on an IV if an infection is suspected. “Then they come up to the floor, and the patent stays on IV antibiotics longer than they need it,” even after infection is ruled out.

IV administration has drawbacks. First it’s expensive, she said. “Levaquin IV is $15, but p.o. is $3. PPI [proton pump inhibitor] is $144 IV but $4 p.o.” And there are other problems such as patients’ pain, having multiple IVs, more nursing care, and more time administering the IV.

The Value Attack’s pitch included enlisting speech and swallowing experts to advise when oral antibiotic doses can substitute. Their idea generated $50,000.

Another team, the “Invaluables,” proposed “Just in time discharge” which would use night hospitalists to discharge patients in the evening, if they’re ready to go home and a ride is available, instead of waiting until morning. Dr. Peter Kaboli, chief of medicine at Iowa City VA Medical Center, said at his hospital, as many as 2 patients of up to 12 discharged a day might be able to go home 15 hours earlier, alleviating boarding in the ED for patients who otherwise wait overnight.

“Our culture is that patients don’t leave after 6 p.m.,” even if they’re ready to go, and a ride is ready, Dr. Kaboli said. He acknowledged the concept is not yet based on evidence, “so we’re kind of sticking our necks out here, but nothing ventured, nothing gained.” The team proposed testing discharges by night shift hospitalists. Their idea was awarded $50,000 by the sharks.

The winning Shark Tank team was the Cost Cutters, who proposed “Standup to Syncope” as their project. Dr. Celene Goetz, a hospitalist at Mount Sinai Medical Center in New York, said all too often, healthy nontrauma patients come into the ED because they fainted, usually because they were dehydrated and called 911, and receive a costly head CT scan and unnecessary radiation exposure.

For many of these patients, taking orthostatic vital signs would rule out CT and reduce admissions, not to mention time in the ED. The problem, she explained in an interview, is that ED physicians don’t do the orthostatic, which requires 5 minutes or more of monitoring the patient’s blood pressure.

“That takes so much of a practitioner’s time, and it’s just easier to order the head CT and put a patient on telemetry,” Dr. Goetz said, noting that ED physicians are often worried about lawsuits from missing a stroke or intracranial hemorrhage.

In a poster presented at the conference, Dr. Goetz reported on 162 patients presenting to the ED with syncope. Of these, 71, or 43.6%, got a head CT, and half of these were inappropriate according to American College of Emergency Physicians’ recommendations. Additionally, “none of the head CTs identified an intracranial bleed or changed management.” Further, “if inappropriate head CTs were not ordered for this group of patients, the hospital could have saved at least $8,680 per year,” Dr. Goetz said.

The “sharks” said this was the best idea, and awarded the winning Cost Cutters $70,000.

[email protected]

SAN DIEGO – With approximately 100,000 mHealth (or mobile health) apps and 13,000 medical apps available to mobile device users, how should a hospitalist physician choose among those that claim to offer decision support at the point of care?

Hospitalists Dr. Bradley J. Benson, professor of internal medicine and pediatric care at the University of Minnesota, Minneapolis, and Dr. J. Richard Pittman Jr. of the department of medicine at Emory University, Atlanta, addressed that question at the 2016 annual conference of the Society of Hospital Medicine by first laying out their two essential criteria: a combination of “the wow factor” and “the quadruple aim.”

Dr. Benson explained that by “wow factor,” he wasn’t talking about “the glitzy, latest, coolest thing with bells and buzzers.” Rather, he said, the term means whether an app was used during “an authentic week on the wards. Did we actually take this thing out and use it to care for patients?”

And the second criteria, the “quadruple aim,” indicates how well the app “improves our ultimate goal. Better outcomes for our patients, better experiences for our patients, better value, and a better experience for us in providing care,” he said.

Here are the Top 10 medical decision support apps for hospitalists, as assessed by Dr. Benson and Dr. Pittman:

1. MDCalc – Free online. $10 app

Helps doctors calculate adverse event risks, such as stroke, bleeding, or clots. For example, Dr. Benson said, you could ask the app what is likely to happen to a 72-year-old observation patient with new atrial fibrillation if she is prescribed warfarin versus aspirin?

This clinical calculator computes the CHA2DS2-VASc score and shows the published medical research on which it is based, he said. “These calculators never have all the ones you’ll need, however. You’re going to need three or four.”

2. Calculate QxMD – Free

Helps determine emergency department patients’ suitability for discharge versus admission, such as for a 74-year-old ED patient with community-acquired pneumonia who was discharged with cellulitis 24 days prior, 6 days shorter than 30 days.

The app concluded “this patient may be appropriate for outpatient therapy,” said Dr. Pittman. “You still use your clinical judgment, but you do have some support if you want to send this patient home and avoid the readmission.” The app, he said, has “most of the calculators I need on a regular basis.”

3. NSQIP’s Surgical Risk Calculator – Free Web-based

Hospitalists are often an important voice on surgical appropriateness, and the American College of Surgeon’s National Surgical Quality Improvement Program’s app helps score that risk.

“What I love about this is that I can tailor it with the actual DRG [diagnosis-related group] for this procedure,” Dr. Benson said. “And it’s based on 1.4 million surgeries and their outcomes.” The risk calculator provides weights for other comorbidities, such as hypertension, “so I can say this patient is at higher risk [of complications] because of x, y, z … and email it to the surgeon. Bottom line is that I can cut and paste this into my note, and that’s what I will go over with the patient.”

4. Seattle Heart Failure Model – Free as Web app

Here’s a 65-year-old man with advanced heart failure and an ejection fraction of 25%, said Dr. Pittman. “He and his family want to talk about whether aggressive interventions prolong life and are worth it. It feels like, in our practice, we spend a lot of time bringing peoples’ expectations down, realistically, from where they are.”

The SHFM is a Web app that can be customized to use on a phone browser. “It’s a validated tool to give guidance about what’s the prognosis for patients living with heart failure,” Dr. Pittman said. “What’s cool is that you can plug in many of their baseline characteristics and demonstrate what happens with different interventions.”

A physician can ask the app what would happen to life expectancy if the patient received a beta-blocker? “We’re going to go from 4.2 to 5.7 years. And what about adding an ICD [implantable cardioverter defibrillator]? You go from 4.2 to 8.4 years.”

5. Lace Index Tool – Free

This app predicts the likelihood a patient will be back to the hospital within the next 30 days based on LACE: length of prior stay, acuity, comorbidities, and number of ED visits within the last 6 months. It helps clinicians “really focus limited resources to prevent readmissions on the right people,” Dr. Benson said.

Take a patient with advanced liver disease admitted with hepatic encephalopathy who is about to be discharged after a 6-day stay and has had three previous ED visits within the last 6 months, he said.

At his hospital, “we peer review every 7-day readmit, not to look at the individual but to look at whether we can learn from it and ask, can we prevent it.”

The index “documents the score and the reasons,” suggesting “if anybody ever needed medical home postdischarge intervention, it’s this guy.” The index also may help providers decide timing for palliative care discussions, he said.

6. Sanford Guide to Antimicrobial Therapy – $29.99/year and GoodRx – Free

“We occasionally get a page: Please discharge your patients. Stop holding them in the hospital,” Dr. Pittman said. That sometimes happens because a patient about to be discharged has a lab come back showing an infection in their urine, and it’s tough to figure out which antibiotic to prescribe.

“If ever a book were meant to be digitized, it’s this Sanford Guide,” he said. It provides the best regimens for which drugs to use, but not their costs.

But what about cost? An app called GoodRx gives prices for drugs at pharmacies within a certain distance. “It levels the playing field for the seeming racket that is drug pricing,” Dr. Pittman said. “You type in the medication, and it overlays a map with pharmacies nearby, and links those prices.”

For example, one drug option, fosfomycin, will cost $70-$80, which may be too high for a patient, while another, nitrofurantoin, costs $23-$28. “That looks a lot better, and you just saved your patient $50.”

7. CORE – $39.99

A 22-year-old chemical dependency unit inpatient complains of knee pain after sitting in long group sessions and wants dilaudid. “How can the hospitalist test for patellofemoral syndrome?” Dr. Benson asks.

The physician turns to CORE, or the Clinical Orthopedic Exam, which can show a nonspecialist how to recognize a true orthopedic problem for multiple body sites, he said. The app shows how to perform 67 tests on the knee, in this case, with 94% diagnostic accuracy, and links to YouTube videos demonstrating the proper way to administer the “moving patellar apprehension” test.

8. VisualDx – $99 a year

A young male patient is admitted with visual changes and a palmar rash, and the hospitalist doesn’t know what to do, Dr. Pittman says. This app provides a homunculus and ways to describe the rash, including pictures one can use to match the patient’s symptoms.

“Instead of the one thing on your list, which was syphilis, the patient and his wife will be so relieved that the rash is actually just dyshidrotic dermatitis.”

9. ARUP Consult – Free online

An admission from the ED brings a 58-year-old woman with acute kidney injury suspected of having vasculitis. What’s the work-up?

Dr. Benson turns to this diagnostic lab reference guide produced by a nonprofit affiliate of the University of Utah, Salt Lake City, to select and interpret tests. “I type vasculitis,” and it shows some options and algorithms, with links to pertinent guidelines, and identifies the medical reviewer during the last update.

“This is critical when there’s a shelf life on knowledge. And the price is right,” he said.

10. Evernote – Free

“This is my favorite app,” Dr. Pittman said. “Not only for personal use, but for making professional notes as well.” A team folder, shared with his colleagues, “becomes a record of what we’ve learned during the month.”

It holds journal articles, recordings, notes, attachments, and photographs of things to remember, he said.

Dr. Benson and Dr. Pittman had no financial conflicts of interest to disclose.

SAN DIEGO – With approximately 100,000 mHealth (or mobile health) apps and 13,000 medical apps available to mobile device users, how should a hospitalist physician choose among those that claim to offer decision support at the point of care?

Hospitalists Dr. Bradley J. Benson, professor of internal medicine and pediatric care at the University of Minnesota, Minneapolis, and Dr. J. Richard Pittman Jr. of the department of medicine at Emory University, Atlanta, addressed that question at the 2016 annual conference of the Society of Hospital Medicine by first laying out their two essential criteria: a combination of “the wow factor” and “the quadruple aim.”

Dr. Benson explained that by “wow factor,” he wasn’t talking about “the glitzy, latest, coolest thing with bells and buzzers.” Rather, he said, the term means whether an app was used during “an authentic week on the wards. Did we actually take this thing out and use it to care for patients?”

And the second criteria, the “quadruple aim,” indicates how well the app “improves our ultimate goal. Better outcomes for our patients, better experiences for our patients, better value, and a better experience for us in providing care,” he said.

Here are the Top 10 medical decision support apps for hospitalists, as assessed by Dr. Benson and Dr. Pittman:

1. MDCalc – Free online. $10 app

Helps doctors calculate adverse event risks, such as stroke, bleeding, or clots. For example, Dr. Benson said, you could ask the app what is likely to happen to a 72-year-old observation patient with new atrial fibrillation if she is prescribed warfarin versus aspirin?

This clinical calculator computes the CHA2DS2-VASc score and shows the published medical research on which it is based, he said. “These calculators never have all the ones you’ll need, however. You’re going to need three or four.”

2. Calculate QxMD – Free

Helps determine emergency department patients’ suitability for discharge versus admission, such as for a 74-year-old ED patient with community-acquired pneumonia who was discharged with cellulitis 24 days prior, 6 days shorter than 30 days.

The app concluded “this patient may be appropriate for outpatient therapy,” said Dr. Pittman. “You still use your clinical judgment, but you do have some support if you want to send this patient home and avoid the readmission.” The app, he said, has “most of the calculators I need on a regular basis.”

3. NSQIP’s Surgical Risk Calculator – Free Web-based

Hospitalists are often an important voice on surgical appropriateness, and the American College of Surgeon’s National Surgical Quality Improvement Program’s app helps score that risk.

“What I love about this is that I can tailor it with the actual DRG [diagnosis-related group] for this procedure,” Dr. Benson said. “And it’s based on 1.4 million surgeries and their outcomes.” The risk calculator provides weights for other comorbidities, such as hypertension, “so I can say this patient is at higher risk [of complications] because of x, y, z … and email it to the surgeon. Bottom line is that I can cut and paste this into my note, and that’s what I will go over with the patient.”

4. Seattle Heart Failure Model – Free as Web app

Here’s a 65-year-old man with advanced heart failure and an ejection fraction of 25%, said Dr. Pittman. “He and his family want to talk about whether aggressive interventions prolong life and are worth it. It feels like, in our practice, we spend a lot of time bringing peoples’ expectations down, realistically, from where they are.”

The SHFM is a Web app that can be customized to use on a phone browser. “It’s a validated tool to give guidance about what’s the prognosis for patients living with heart failure,” Dr. Pittman said. “What’s cool is that you can plug in many of their baseline characteristics and demonstrate what happens with different interventions.”

A physician can ask the app what would happen to life expectancy if the patient received a beta-blocker? “We’re going to go from 4.2 to 5.7 years. And what about adding an ICD [implantable cardioverter defibrillator]? You go from 4.2 to 8.4 years.”

5. Lace Index Tool – Free

This app predicts the likelihood a patient will be back to the hospital within the next 30 days based on LACE: length of prior stay, acuity, comorbidities, and number of ED visits within the last 6 months. It helps clinicians “really focus limited resources to prevent readmissions on the right people,” Dr. Benson said.

Take a patient with advanced liver disease admitted with hepatic encephalopathy who is about to be discharged after a 6-day stay and has had three previous ED visits within the last 6 months, he said.

At his hospital, “we peer review every 7-day readmit, not to look at the individual but to look at whether we can learn from it and ask, can we prevent it.”

The index “documents the score and the reasons,” suggesting “if anybody ever needed medical home postdischarge intervention, it’s this guy.” The index also may help providers decide timing for palliative care discussions, he said.

6. Sanford Guide to Antimicrobial Therapy – $29.99/year and GoodRx – Free

“We occasionally get a page: Please discharge your patients. Stop holding them in the hospital,” Dr. Pittman said. That sometimes happens because a patient about to be discharged has a lab come back showing an infection in their urine, and it’s tough to figure out which antibiotic to prescribe.

“If ever a book were meant to be digitized, it’s this Sanford Guide,” he said. It provides the best regimens for which drugs to use, but not their costs.

But what about cost? An app called GoodRx gives prices for drugs at pharmacies within a certain distance. “It levels the playing field for the seeming racket that is drug pricing,” Dr. Pittman said. “You type in the medication, and it overlays a map with pharmacies nearby, and links those prices.”

For example, one drug option, fosfomycin, will cost $70-$80, which may be too high for a patient, while another, nitrofurantoin, costs $23-$28. “That looks a lot better, and you just saved your patient $50.”

7. CORE – $39.99

A 22-year-old chemical dependency unit inpatient complains of knee pain after sitting in long group sessions and wants dilaudid. “How can the hospitalist test for patellofemoral syndrome?” Dr. Benson asks.

The physician turns to CORE, or the Clinical Orthopedic Exam, which can show a nonspecialist how to recognize a true orthopedic problem for multiple body sites, he said. The app shows how to perform 67 tests on the knee, in this case, with 94% diagnostic accuracy, and links to YouTube videos demonstrating the proper way to administer the “moving patellar apprehension” test.

8. VisualDx – $99 a year

A young male patient is admitted with visual changes and a palmar rash, and the hospitalist doesn’t know what to do, Dr. Pittman says. This app provides a homunculus and ways to describe the rash, including pictures one can use to match the patient’s symptoms.

“Instead of the one thing on your list, which was syphilis, the patient and his wife will be so relieved that the rash is actually just dyshidrotic dermatitis.”

9. ARUP Consult – Free online

An admission from the ED brings a 58-year-old woman with acute kidney injury suspected of having vasculitis. What’s the work-up?

Dr. Benson turns to this diagnostic lab reference guide produced by a nonprofit affiliate of the University of Utah, Salt Lake City, to select and interpret tests. “I type vasculitis,” and it shows some options and algorithms, with links to pertinent guidelines, and identifies the medical reviewer during the last update.

“This is critical when there’s a shelf life on knowledge. And the price is right,” he said.

10. Evernote – Free

“This is my favorite app,” Dr. Pittman said. “Not only for personal use, but for making professional notes as well.” A team folder, shared with his colleagues, “becomes a record of what we’ve learned during the month.”

It holds journal articles, recordings, notes, attachments, and photographs of things to remember, he said.

Dr. Benson and Dr. Pittman had no financial conflicts of interest to disclose.

SAN DIEGO – With approximately 100,000 mHealth (or mobile health) apps and 13,000 medical apps available to mobile device users, how should a hospitalist physician choose among those that claim to offer decision support at the point of care?

Hospitalists Dr. Bradley J. Benson, professor of internal medicine and pediatric care at the University of Minnesota, Minneapolis, and Dr. J. Richard Pittman Jr. of the department of medicine at Emory University, Atlanta, addressed that question at the 2016 annual conference of the Society of Hospital Medicine by first laying out their two essential criteria: a combination of “the wow factor” and “the quadruple aim.”

Dr. Benson explained that by “wow factor,” he wasn’t talking about “the glitzy, latest, coolest thing with bells and buzzers.” Rather, he said, the term means whether an app was used during “an authentic week on the wards. Did we actually take this thing out and use it to care for patients?”

And the second criteria, the “quadruple aim,” indicates how well the app “improves our ultimate goal. Better outcomes for our patients, better experiences for our patients, better value, and a better experience for us in providing care,” he said.

Here are the Top 10 medical decision support apps for hospitalists, as assessed by Dr. Benson and Dr. Pittman:

1. MDCalc – Free online. $10 app

Helps doctors calculate adverse event risks, such as stroke, bleeding, or clots. For example, Dr. Benson said, you could ask the app what is likely to happen to a 72-year-old observation patient with new atrial fibrillation if she is prescribed warfarin versus aspirin?

This clinical calculator computes the CHA2DS2-VASc score and shows the published medical research on which it is based, he said. “These calculators never have all the ones you’ll need, however. You’re going to need three or four.”

2. Calculate QxMD – Free

Helps determine emergency department patients’ suitability for discharge versus admission, such as for a 74-year-old ED patient with community-acquired pneumonia who was discharged with cellulitis 24 days prior, 6 days shorter than 30 days.

The app concluded “this patient may be appropriate for outpatient therapy,” said Dr. Pittman. “You still use your clinical judgment, but you do have some support if you want to send this patient home and avoid the readmission.” The app, he said, has “most of the calculators I need on a regular basis.”

3. NSQIP’s Surgical Risk Calculator – Free Web-based

Hospitalists are often an important voice on surgical appropriateness, and the American College of Surgeon’s National Surgical Quality Improvement Program’s app helps score that risk.

“What I love about this is that I can tailor it with the actual DRG [diagnosis-related group] for this procedure,” Dr. Benson said. “And it’s based on 1.4 million surgeries and their outcomes.” The risk calculator provides weights for other comorbidities, such as hypertension, “so I can say this patient is at higher risk [of complications] because of x, y, z … and email it to the surgeon. Bottom line is that I can cut and paste this into my note, and that’s what I will go over with the patient.”

4. Seattle Heart Failure Model – Free as Web app

Here’s a 65-year-old man with advanced heart failure and an ejection fraction of 25%, said Dr. Pittman. “He and his family want to talk about whether aggressive interventions prolong life and are worth it. It feels like, in our practice, we spend a lot of time bringing peoples’ expectations down, realistically, from where they are.”

The SHFM is a Web app that can be customized to use on a phone browser. “It’s a validated tool to give guidance about what’s the prognosis for patients living with heart failure,” Dr. Pittman said. “What’s cool is that you can plug in many of their baseline characteristics and demonstrate what happens with different interventions.”

A physician can ask the app what would happen to life expectancy if the patient received a beta-blocker? “We’re going to go from 4.2 to 5.7 years. And what about adding an ICD [implantable cardioverter defibrillator]? You go from 4.2 to 8.4 years.”

5. Lace Index Tool – Free

This app predicts the likelihood a patient will be back to the hospital within the next 30 days based on LACE: length of prior stay, acuity, comorbidities, and number of ED visits within the last 6 months. It helps clinicians “really focus limited resources to prevent readmissions on the right people,” Dr. Benson said.

Take a patient with advanced liver disease admitted with hepatic encephalopathy who is about to be discharged after a 6-day stay and has had three previous ED visits within the last 6 months, he said.

At his hospital, “we peer review every 7-day readmit, not to look at the individual but to look at whether we can learn from it and ask, can we prevent it.”

The index “documents the score and the reasons,” suggesting “if anybody ever needed medical home postdischarge intervention, it’s this guy.” The index also may help providers decide timing for palliative care discussions, he said.

6. Sanford Guide to Antimicrobial Therapy – $29.99/year and GoodRx – Free

“We occasionally get a page: Please discharge your patients. Stop holding them in the hospital,” Dr. Pittman said. That sometimes happens because a patient about to be discharged has a lab come back showing an infection in their urine, and it’s tough to figure out which antibiotic to prescribe.

“If ever a book were meant to be digitized, it’s this Sanford Guide,” he said. It provides the best regimens for which drugs to use, but not their costs.

But what about cost? An app called GoodRx gives prices for drugs at pharmacies within a certain distance. “It levels the playing field for the seeming racket that is drug pricing,” Dr. Pittman said. “You type in the medication, and it overlays a map with pharmacies nearby, and links those prices.”

For example, one drug option, fosfomycin, will cost $70-$80, which may be too high for a patient, while another, nitrofurantoin, costs $23-$28. “That looks a lot better, and you just saved your patient $50.”

7. CORE – $39.99

A 22-year-old chemical dependency unit inpatient complains of knee pain after sitting in long group sessions and wants dilaudid. “How can the hospitalist test for patellofemoral syndrome?” Dr. Benson asks.

The physician turns to CORE, or the Clinical Orthopedic Exam, which can show a nonspecialist how to recognize a true orthopedic problem for multiple body sites, he said. The app shows how to perform 67 tests on the knee, in this case, with 94% diagnostic accuracy, and links to YouTube videos demonstrating the proper way to administer the “moving patellar apprehension” test.

8. VisualDx – $99 a year

A young male patient is admitted with visual changes and a palmar rash, and the hospitalist doesn’t know what to do, Dr. Pittman says. This app provides a homunculus and ways to describe the rash, including pictures one can use to match the patient’s symptoms.

“Instead of the one thing on your list, which was syphilis, the patient and his wife will be so relieved that the rash is actually just dyshidrotic dermatitis.”

9. ARUP Consult – Free online

An admission from the ED brings a 58-year-old woman with acute kidney injury suspected of having vasculitis. What’s the work-up?

Dr. Benson turns to this diagnostic lab reference guide produced by a nonprofit affiliate of the University of Utah, Salt Lake City, to select and interpret tests. “I type vasculitis,” and it shows some options and algorithms, with links to pertinent guidelines, and identifies the medical reviewer during the last update.

“This is critical when there’s a shelf life on knowledge. And the price is right,” he said.

10. Evernote – Free

“This is my favorite app,” Dr. Pittman said. “Not only for personal use, but for making professional notes as well.” A team folder, shared with his colleagues, “becomes a record of what we’ve learned during the month.”

It holds journal articles, recordings, notes, attachments, and photographs of things to remember, he said.

Dr. Benson and Dr. Pittman had no financial conflicts of interest to disclose.

LAS VEGAS – Doctors are dreading what some have started to call EHR "pajama time.”

“That’s the hour or two that physicians are spending – every night after their kids go to bed – finishing up their documentation, clearing out their in-box,” according to Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days.

Leah-Anne Thompson/Thinkstock

Data on the impact of EHR systems on physicians’ workflows and satisfaction is beginning to accumulate, she said. University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records, she said. What they found was that so many doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up. Their preliminary findings were presented in 2015 at a primary care research meeting.

Dr. Sinsky said the researchers see “a bump” of time spent on Saturday nights.

“I call that ‘date night’. That Saturday night belongs to Epic, Cerner, or McKesson,” she said sarcastically. “Well, I don’t want my doctor on her electronic health record on a Saturday night. I want my doctor having fun on Saturday night, because I want her to love her job.”

That same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work,” in other words “working a full extra week every month doing documentation after hours, between 7 p.m. and 7 a.m.,” said Dr. Sinky, who is also an internist in Dubuque, Iowa.

Here are 10 ways EHRs contribute to more work, Dr. Sinsky said:

1. Too many clicks. “It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift,” Dr. Sinsky said. “Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”

In her own EHR, she said, “it took 21 clicks, eight scrolls, and five screens just to compose the billing invoice, and within that EHR, the responsibility, which used to be a clerical responsibility, has transferred many things to the physician. All of those clicks, all those screens, and all those minutes add up.”

2. Note bloat. With her current EHR, Dr. Sinksy said, “I have six pages of notes for an upper respiratory infection.” This is not efficient. She offered another example: “I had a patient recently who I sent to a local university,” Dr. Sinsky said. “I got back an enormous note, about 12 pages long. But I still didn’t know, at the end of it. Did she have cancer, or not?”

3. Poor workflow. Today’s EHRs have a workflow that doesn’t match how clinicians work, she said. “Right now, many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.” For example, “in some EHRs, the physician can’t look at any clinical data while dictating the note. This means that the physician has to rely on memory or print lab results, x-ray reports, medication lists, etc., in order to reference these data points in their clinic note.”

4. A lack of focus on the patient. Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.

5. No support for team care. Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. “The nurse has to sign in and sign out; the doctor has to sign in and sign out. That’s about a 2-minute process, so it’s completely unworkable,” Dr. Sinsky said.

6. Distracted hikes to the printer. While most health care settings have installed the computer in the exam rooms, few have also installed a printer. “The doctor types up the exit summary, hits print, runs around the corner, down the hall, around the corner to the one printer, picks up the visit summary, goes back down the corner down the hall. Meanwhile, they’ve broken their bond with the patient and been interrupted several times on that journey.”

7. Single-use workstations. Doctors who can sit side by side with their nurses and talk about the patient as they’re working on the EHR can save 30 minutes per day. But most office practice setups don’t accommodate that interaction.

8. Small monitors. Being able to see a large display of information rather than a tiny swatch can save 20 minutes of physician time a day, Dr. Sinsky said.

9. A long sign-in process. Streamlining the way a doctor signs into a computer, perhaps with the use of technologies like the tap of one’s badge, “can save 14 minutes of physician time a day,” Dr. Sinsky said.

10. Underuse of medical and nursing students. Practices are beginning to hire premed and prenursing students as assistants who shadow the physician with each patient. While the physician is “giving undivided attention to the patient, the practice partner is cuing up the orders, doing the billing invoice ,and recording much of the encounter.” At the University of California, Los Angeles, researchers found that the use of these assistants saves 3 hours of physician time each day (JAMA Intern Med. 2014;174[7]:1190-3).

LAS VEGAS – Doctors are dreading what some have started to call EHR "pajama time.”

“That’s the hour or two that physicians are spending – every night after their kids go to bed – finishing up their documentation, clearing out their in-box,” according to Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days.

Leah-Anne Thompson/Thinkstock

Data on the impact of EHR systems on physicians’ workflows and satisfaction is beginning to accumulate, she said. University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records, she said. What they found was that so many doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up. Their preliminary findings were presented in 2015 at a primary care research meeting.

Dr. Sinsky said the researchers see “a bump” of time spent on Saturday nights.

“I call that ‘date night’. That Saturday night belongs to Epic, Cerner, or McKesson,” she said sarcastically. “Well, I don’t want my doctor on her electronic health record on a Saturday night. I want my doctor having fun on Saturday night, because I want her to love her job.”

That same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work,” in other words “working a full extra week every month doing documentation after hours, between 7 p.m. and 7 a.m.,” said Dr. Sinky, who is also an internist in Dubuque, Iowa.

Here are 10 ways EHRs contribute to more work, Dr. Sinsky said:

1. Too many clicks. “It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift,” Dr. Sinsky said. “Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”

In her own EHR, she said, “it took 21 clicks, eight scrolls, and five screens just to compose the billing invoice, and within that EHR, the responsibility, which used to be a clerical responsibility, has transferred many things to the physician. All of those clicks, all those screens, and all those minutes add up.”

2. Note bloat. With her current EHR, Dr. Sinksy said, “I have six pages of notes for an upper respiratory infection.” This is not efficient. She offered another example: “I had a patient recently who I sent to a local university,” Dr. Sinsky said. “I got back an enormous note, about 12 pages long. But I still didn’t know, at the end of it. Did she have cancer, or not?”

3. Poor workflow. Today’s EHRs have a workflow that doesn’t match how clinicians work, she said. “Right now, many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.” For example, “in some EHRs, the physician can’t look at any clinical data while dictating the note. This means that the physician has to rely on memory or print lab results, x-ray reports, medication lists, etc., in order to reference these data points in their clinic note.”

4. A lack of focus on the patient. Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.

5. No support for team care. Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. “The nurse has to sign in and sign out; the doctor has to sign in and sign out. That’s about a 2-minute process, so it’s completely unworkable,” Dr. Sinsky said.

6. Distracted hikes to the printer. While most health care settings have installed the computer in the exam rooms, few have also installed a printer. “The doctor types up the exit summary, hits print, runs around the corner, down the hall, around the corner to the one printer, picks up the visit summary, goes back down the corner down the hall. Meanwhile, they’ve broken their bond with the patient and been interrupted several times on that journey.”

7. Single-use workstations. Doctors who can sit side by side with their nurses and talk about the patient as they’re working on the EHR can save 30 minutes per day. But most office practice setups don’t accommodate that interaction.

8. Small monitors. Being able to see a large display of information rather than a tiny swatch can save 20 minutes of physician time a day, Dr. Sinsky said.

9. A long sign-in process. Streamlining the way a doctor signs into a computer, perhaps with the use of technologies like the tap of one’s badge, “can save 14 minutes of physician time a day,” Dr. Sinsky said.

10. Underuse of medical and nursing students. Practices are beginning to hire premed and prenursing students as assistants who shadow the physician with each patient. While the physician is “giving undivided attention to the patient, the practice partner is cuing up the orders, doing the billing invoice ,and recording much of the encounter.” At the University of California, Los Angeles, researchers found that the use of these assistants saves 3 hours of physician time each day (JAMA Intern Med. 2014;174[7]:1190-3).

LAS VEGAS – Doctors are dreading what some have started to call EHR "pajama time.”

“That’s the hour or two that physicians are spending – every night after their kids go to bed – finishing up their documentation, clearing out their in-box,” according to Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days.

Leah-Anne Thompson/Thinkstock

Data on the impact of EHR systems on physicians’ workflows and satisfaction is beginning to accumulate, she said. University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records, she said. What they found was that so many doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up. Their preliminary findings were presented in 2015 at a primary care research meeting.

Dr. Sinsky said the researchers see “a bump” of time spent on Saturday nights.

“I call that ‘date night’. That Saturday night belongs to Epic, Cerner, or McKesson,” she said sarcastically. “Well, I don’t want my doctor on her electronic health record on a Saturday night. I want my doctor having fun on Saturday night, because I want her to love her job.”

That same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work,” in other words “working a full extra week every month doing documentation after hours, between 7 p.m. and 7 a.m.,” said Dr. Sinky, who is also an internist in Dubuque, Iowa.

Here are 10 ways EHRs contribute to more work, Dr. Sinsky said:

1. Too many clicks. “It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift,” Dr. Sinsky said. “Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”

In her own EHR, she said, “it took 21 clicks, eight scrolls, and five screens just to compose the billing invoice, and within that EHR, the responsibility, which used to be a clerical responsibility, has transferred many things to the physician. All of those clicks, all those screens, and all those minutes add up.”

2. Note bloat. With her current EHR, Dr. Sinksy said, “I have six pages of notes for an upper respiratory infection.” This is not efficient. She offered another example: “I had a patient recently who I sent to a local university,” Dr. Sinsky said. “I got back an enormous note, about 12 pages long. But I still didn’t know, at the end of it. Did she have cancer, or not?”

3. Poor workflow. Today’s EHRs have a workflow that doesn’t match how clinicians work, she said. “Right now, many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.” For example, “in some EHRs, the physician can’t look at any clinical data while dictating the note. This means that the physician has to rely on memory or print lab results, x-ray reports, medication lists, etc., in order to reference these data points in their clinic note.”

4. A lack of focus on the patient. Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.

5. No support for team care. Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. “The nurse has to sign in and sign out; the doctor has to sign in and sign out. That’s about a 2-minute process, so it’s completely unworkable,” Dr. Sinsky said.

6. Distracted hikes to the printer. While most health care settings have installed the computer in the exam rooms, few have also installed a printer. “The doctor types up the exit summary, hits print, runs around the corner, down the hall, around the corner to the one printer, picks up the visit summary, goes back down the corner down the hall. Meanwhile, they’ve broken their bond with the patient and been interrupted several times on that journey.”

7. Single-use workstations. Doctors who can sit side by side with their nurses and talk about the patient as they’re working on the EHR can save 30 minutes per day. But most office practice setups don’t accommodate that interaction.

8. Small monitors. Being able to see a large display of information rather than a tiny swatch can save 20 minutes of physician time a day, Dr. Sinsky said.

9. A long sign-in process. Streamlining the way a doctor signs into a computer, perhaps with the use of technologies like the tap of one’s badge, “can save 14 minutes of physician time a day,” Dr. Sinsky said.

10. Underuse of medical and nursing students. Practices are beginning to hire premed and prenursing students as assistants who shadow the physician with each patient. While the physician is “giving undivided attention to the patient, the practice partner is cuing up the orders, doing the billing invoice ,and recording much of the encounter.” At the University of California, Los Angeles, researchers found that the use of these assistants saves 3 hours of physician time each day (JAMA Intern Med. 2014;174[7]:1190-3).

SAN DIEGO –If hospitalists want to do well when bundled payment models kick in, they must help to direct the choice of post-discharge care settings for their patients.

That means making sure hospitalists only recommend more expensive care, such as that provided in long-term facilities and skilled nursing homes, for those patients who truly need it.

And it means assuring that facilities selected for their networks have low readmission rates and high-quality track records.

Those were some of the messages from three speakers at the annual meeting of the Society of Hospital Medicine who discussed “Moving from Fee for Service to Value-Based Purchasing and Bundled Payment Models.”

“We have to look outside the four walls of the hospital in the future if we want to continue to make health care better,” said Dr. Winthrop Whitcomb, chief medical officer for the consulting group Remedy Partners of Darien, Conn.

That will be especially true as providers move to bundled payment models, and begin to absorb risk for any allowable costs incurred during 30, 60, or 90 days post-discharge for various diagnosis-related groups.

In one 90-day bundled model analyzed by Remedy for a number of hospitals, Dr. Whitcomb said, the anchor admission absorbed only 33% of the episode’s spending while readmissions accounted for 17%, skilled nursing facility stays accounted for 22%, and inpatient rehabilitation facilities and long-term care hospitals 4%, collectively more than the anchor admission.

“Patients who are hospitalized and then go home, with or without a home health agency, incur $20,000 over a 90-day episode,” he said. “However, if they go to a skilled nursing facility, it’s two times that.” And while the skilled nursing facility group “may be sicker, there’s an overlap here, and the trick is to figure out which of these patients who go to these higher cost settings can actually go home safely.”

Dr. Whitcomb emphasized “three core skills” hospitalists must master in a bundled payment model:

• More focus on palliative care discussions when appropriate.

• More emphasis on hospitalists’ involvement in patients’ functional assessments to determine the appropriate post acute setting.

• Better “transitionalist” services to manage care prior to admission and after discharge, such as in skilled nursing facilities, home care services, or post-discharge clinics.

The federal Medicare Spending Per Beneficiary measure can mean a significant reward or pay cut for all hospitals, apart from bundled programs. The Medicare Spending Per Beneficiary rate affects 25% of the score used to calculate a hospital’s incentive payment in Medicare’s value-based purchasing program, which this fiscal year amounts to 44 cents of every $100 in Medicare reimbursement at risk, but next year rises to 50 cents.

The hospitalist also should take a more proactive role in recommending certain nursing homes and other post-discharge services over others based on outcomes, emphasized Dr. Robert Bessler, founder and CEO of Sound Physicians, a Tacoma, Wash.–based hospital physicians’ group.

“We moved our patients from the bad home health agency to the good one, without doing anything else, and saved $1,265 per episode, plus eight patients don’t get readmitted,” Dr. Bessler said. Similar quality information should inform decisions about which nursing homes these patients should be discharged to, “not where case management last got donuts, or who has a bed available, but who has good outcomes,” he said.

He added that the system can save $13,000 per patient, with four less readmissions, just by using the data available. “This is what’s making real winners and losers in the nursing home space, competition for free market at its best,” he said.

The potential for savings is huge because half of every healthcare dollar spent happens within 90 days of a hospital stay and in those 90 days, in all settings, there is large variation nationally.

“The stat that blew me away the first time I heard it was the skilled nursing facility bed days per 1,000 patients for seniors in Kaiser in California is about 600. However, if you’re in fee for service anywhere in the country, in Ohio or South Florida, the average skilled nursing facility bed days per 1,000 seniors is 2,000,” Dr. Bessler said.

The hospitalist also can be the arbiter of quality, based on data. Although Medicare requires hospitals list three post-acute facilities that they don’t own for patients making decisions, they can name facilities and services with which they have had good experiences.

Several speakers noted that case managers often misunderstand this, thinking they’re protecting their patients by giving them a wide range of choices. But they may in fact be hurting them by not giving them informed information about the quality levels of those facilities.

Medicare’s five star-rating system for nursing homes can inform those choices, said Dr. George Mitri, chief medical officer for U.S. Acute Care Solutions and former vice president of care coordination and hospital medicine for Aultman Hospital in Canton, Ohio.

Across the country, he said, 40% of the 1.4 million patients who are in nursing homes are in facilities with only one or two stars. “That’s 560,000 patients who are in nursing homes that are providing poor quality, and we don’t know it.”

Those nursing homes are more likely to cost more money through readmissions and other problems affecting the bundled payment, Dr. Mitri said. And, he said, “if you’re a one-star, you’re actually causing harm to the patient.”

As hospitalists look to gauge quality of post-discharge care, Dr. Mitri said they should also look at quality ratings for home health agencies and rehabilitation facilities, where there also is wide variation.

Another way that hospitalists can reduce spending and maximize bundled savings is by paying more attention to documentation and coding through data, Dr. Mitri said.

That means, for example, making sure that a stroke case in diagnosis-related group 64 is not incorrectly coded as a lower-paying 65. “If you have 64s (being coded as) 65s, you’re going to lose money, because you’re using more resources than was intended. If data is king, documentation is queen,” he said.

Using Medicare’s bundled payment model for stroke, Dr. Mitri said, his former hospital “narrowed its network” and was able to “cut down the cost because we cut down length of stay and have better expectations from nursing facilities about what they’re going to do with our patients.”

SAN DIEGO –If hospitalists want to do well when bundled payment models kick in, they must help to direct the choice of post-discharge care settings for their patients.

That means making sure hospitalists only recommend more expensive care, such as that provided in long-term facilities and skilled nursing homes, for those patients who truly need it.

And it means assuring that facilities selected for their networks have low readmission rates and high-quality track records.

Those were some of the messages from three speakers at the annual meeting of the Society of Hospital Medicine who discussed “Moving from Fee for Service to Value-Based Purchasing and Bundled Payment Models.”

“We have to look outside the four walls of the hospital in the future if we want to continue to make health care better,” said Dr. Winthrop Whitcomb, chief medical officer for the consulting group Remedy Partners of Darien, Conn.

That will be especially true as providers move to bundled payment models, and begin to absorb risk for any allowable costs incurred during 30, 60, or 90 days post-discharge for various diagnosis-related groups.

In one 90-day bundled model analyzed by Remedy for a number of hospitals, Dr. Whitcomb said, the anchor admission absorbed only 33% of the episode’s spending while readmissions accounted for 17%, skilled nursing facility stays accounted for 22%, and inpatient rehabilitation facilities and long-term care hospitals 4%, collectively more than the anchor admission.

“Patients who are hospitalized and then go home, with or without a home health agency, incur $20,000 over a 90-day episode,” he said. “However, if they go to a skilled nursing facility, it’s two times that.” And while the skilled nursing facility group “may be sicker, there’s an overlap here, and the trick is to figure out which of these patients who go to these higher cost settings can actually go home safely.”

Dr. Whitcomb emphasized “three core skills” hospitalists must master in a bundled payment model:

• More focus on palliative care discussions when appropriate.

• More emphasis on hospitalists’ involvement in patients’ functional assessments to determine the appropriate post acute setting.

• Better “transitionalist” services to manage care prior to admission and after discharge, such as in skilled nursing facilities, home care services, or post-discharge clinics.

The federal Medicare Spending Per Beneficiary measure can mean a significant reward or pay cut for all hospitals, apart from bundled programs. The Medicare Spending Per Beneficiary rate affects 25% of the score used to calculate a hospital’s incentive payment in Medicare’s value-based purchasing program, which this fiscal year amounts to 44 cents of every $100 in Medicare reimbursement at risk, but next year rises to 50 cents.

The hospitalist also should take a more proactive role in recommending certain nursing homes and other post-discharge services over others based on outcomes, emphasized Dr. Robert Bessler, founder and CEO of Sound Physicians, a Tacoma, Wash.–based hospital physicians’ group.

“We moved our patients from the bad home health agency to the good one, without doing anything else, and saved $1,265 per episode, plus eight patients don’t get readmitted,” Dr. Bessler said. Similar quality information should inform decisions about which nursing homes these patients should be discharged to, “not where case management last got donuts, or who has a bed available, but who has good outcomes,” he said.

He added that the system can save $13,000 per patient, with four less readmissions, just by using the data available. “This is what’s making real winners and losers in the nursing home space, competition for free market at its best,” he said.

The potential for savings is huge because half of every healthcare dollar spent happens within 90 days of a hospital stay and in those 90 days, in all settings, there is large variation nationally.

“The stat that blew me away the first time I heard it was the skilled nursing facility bed days per 1,000 patients for seniors in Kaiser in California is about 600. However, if you’re in fee for service anywhere in the country, in Ohio or South Florida, the average skilled nursing facility bed days per 1,000 seniors is 2,000,” Dr. Bessler said.

The hospitalist also can be the arbiter of quality, based on data. Although Medicare requires hospitals list three post-acute facilities that they don’t own for patients making decisions, they can name facilities and services with which they have had good experiences.

Several speakers noted that case managers often misunderstand this, thinking they’re protecting their patients by giving them a wide range of choices. But they may in fact be hurting them by not giving them informed information about the quality levels of those facilities.

Medicare’s five star-rating system for nursing homes can inform those choices, said Dr. George Mitri, chief medical officer for U.S. Acute Care Solutions and former vice president of care coordination and hospital medicine for Aultman Hospital in Canton, Ohio.

Across the country, he said, 40% of the 1.4 million patients who are in nursing homes are in facilities with only one or two stars. “That’s 560,000 patients who are in nursing homes that are providing poor quality, and we don’t know it.”

Those nursing homes are more likely to cost more money through readmissions and other problems affecting the bundled payment, Dr. Mitri said. And, he said, “if you’re a one-star, you’re actually causing harm to the patient.”

As hospitalists look to gauge quality of post-discharge care, Dr. Mitri said they should also look at quality ratings for home health agencies and rehabilitation facilities, where there also is wide variation.

Another way that hospitalists can reduce spending and maximize bundled savings is by paying more attention to documentation and coding through data, Dr. Mitri said.

That means, for example, making sure that a stroke case in diagnosis-related group 64 is not incorrectly coded as a lower-paying 65. “If you have 64s (being coded as) 65s, you’re going to lose money, because you’re using more resources than was intended. If data is king, documentation is queen,” he said.

Using Medicare’s bundled payment model for stroke, Dr. Mitri said, his former hospital “narrowed its network” and was able to “cut down the cost because we cut down length of stay and have better expectations from nursing facilities about what they’re going to do with our patients.”

SAN DIEGO –If hospitalists want to do well when bundled payment models kick in, they must help to direct the choice of post-discharge care settings for their patients.

That means making sure hospitalists only recommend more expensive care, such as that provided in long-term facilities and skilled nursing homes, for those patients who truly need it.

And it means assuring that facilities selected for their networks have low readmission rates and high-quality track records.

Those were some of the messages from three speakers at the annual meeting of the Society of Hospital Medicine who discussed “Moving from Fee for Service to Value-Based Purchasing and Bundled Payment Models.”

“We have to look outside the four walls of the hospital in the future if we want to continue to make health care better,” said Dr. Winthrop Whitcomb, chief medical officer for the consulting group Remedy Partners of Darien, Conn.

That will be especially true as providers move to bundled payment models, and begin to absorb risk for any allowable costs incurred during 30, 60, or 90 days post-discharge for various diagnosis-related groups.

In one 90-day bundled model analyzed by Remedy for a number of hospitals, Dr. Whitcomb said, the anchor admission absorbed only 33% of the episode’s spending while readmissions accounted for 17%, skilled nursing facility stays accounted for 22%, and inpatient rehabilitation facilities and long-term care hospitals 4%, collectively more than the anchor admission.

“Patients who are hospitalized and then go home, with or without a home health agency, incur $20,000 over a 90-day episode,” he said. “However, if they go to a skilled nursing facility, it’s two times that.” And while the skilled nursing facility group “may be sicker, there’s an overlap here, and the trick is to figure out which of these patients who go to these higher cost settings can actually go home safely.”

Dr. Whitcomb emphasized “three core skills” hospitalists must master in a bundled payment model:

• More focus on palliative care discussions when appropriate.

• More emphasis on hospitalists’ involvement in patients’ functional assessments to determine the appropriate post acute setting.

• Better “transitionalist” services to manage care prior to admission and after discharge, such as in skilled nursing facilities, home care services, or post-discharge clinics.

The federal Medicare Spending Per Beneficiary measure can mean a significant reward or pay cut for all hospitals, apart from bundled programs. The Medicare Spending Per Beneficiary rate affects 25% of the score used to calculate a hospital’s incentive payment in Medicare’s value-based purchasing program, which this fiscal year amounts to 44 cents of every $100 in Medicare reimbursement at risk, but next year rises to 50 cents.

The hospitalist also should take a more proactive role in recommending certain nursing homes and other post-discharge services over others based on outcomes, emphasized Dr. Robert Bessler, founder and CEO of Sound Physicians, a Tacoma, Wash.–based hospital physicians’ group.

“We moved our patients from the bad home health agency to the good one, without doing anything else, and saved $1,265 per episode, plus eight patients don’t get readmitted,” Dr. Bessler said. Similar quality information should inform decisions about which nursing homes these patients should be discharged to, “not where case management last got donuts, or who has a bed available, but who has good outcomes,” he said.

He added that the system can save $13,000 per patient, with four less readmissions, just by using the data available. “This is what’s making real winners and losers in the nursing home space, competition for free market at its best,” he said.

The potential for savings is huge because half of every healthcare dollar spent happens within 90 days of a hospital stay and in those 90 days, in all settings, there is large variation nationally.

“The stat that blew me away the first time I heard it was the skilled nursing facility bed days per 1,000 patients for seniors in Kaiser in California is about 600. However, if you’re in fee for service anywhere in the country, in Ohio or South Florida, the average skilled nursing facility bed days per 1,000 seniors is 2,000,” Dr. Bessler said.

The hospitalist also can be the arbiter of quality, based on data. Although Medicare requires hospitals list three post-acute facilities that they don’t own for patients making decisions, they can name facilities and services with which they have had good experiences.

Several speakers noted that case managers often misunderstand this, thinking they’re protecting their patients by giving them a wide range of choices. But they may in fact be hurting them by not giving them informed information about the quality levels of those facilities.

Medicare’s five star-rating system for nursing homes can inform those choices, said Dr. George Mitri, chief medical officer for U.S. Acute Care Solutions and former vice president of care coordination and hospital medicine for Aultman Hospital in Canton, Ohio.

Across the country, he said, 40% of the 1.4 million patients who are in nursing homes are in facilities with only one or two stars. “That’s 560,000 patients who are in nursing homes that are providing poor quality, and we don’t know it.”

Those nursing homes are more likely to cost more money through readmissions and other problems affecting the bundled payment, Dr. Mitri said. And, he said, “if you’re a one-star, you’re actually causing harm to the patient.”

As hospitalists look to gauge quality of post-discharge care, Dr. Mitri said they should also look at quality ratings for home health agencies and rehabilitation facilities, where there also is wide variation.

Another way that hospitalists can reduce spending and maximize bundled savings is by paying more attention to documentation and coding through data, Dr. Mitri said.

That means, for example, making sure that a stroke case in diagnosis-related group 64 is not incorrectly coded as a lower-paying 65. “If you have 64s (being coded as) 65s, you’re going to lose money, because you’re using more resources than was intended. If data is king, documentation is queen,” he said.

Using Medicare’s bundled payment model for stroke, Dr. Mitri said, his former hospital “narrowed its network” and was able to “cut down the cost because we cut down length of stay and have better expectations from nursing facilities about what they’re going to do with our patients.”

SAN DIEGO – The time has come to do away with the 12-hours-a-day, “7-on, 7-off” schedules followed by nearly all hospitalist groups, according to Dr. Robert Wachter, professor of medicine at the University of California, San Francisco, and father of the hospitalist movement.

To institutionalize such a schedule so broadly in the specialty’s earliest years “was a mistake, a well-meaning, understandable mistake … [but now] it feels like a real error that probably needs to be rethought,” Dr. Wachter said in his closing address at the Society of Hospital Medicine’s annual conference. The model is “fine for a 35-year-old,” he said, “but not so doable for a 55-year-old.”

In a follow-up phone interview, Dr. Wachter explained he’s increasingly hearing “tales of burnout from hospitalists” who are not as young as they used to be. And while burnout is a problem plaguing several medical specialties, “when you drill down and try to understand the source, it sounds like [hospitalists] are running for the entire day for 12 hours, and doing it 7 days a week. I don’t know many 50-year-olds who can do that” in a building where patients are on many floors, he said, noting that hospitalized patients are sicker and more complex.

Dr. Wachter said the hospitalist model is now used by between 70% and 90% of the nation’s hospitals, which given the number of recruiting advertisements in journals, are having a hard time filling hospitalist positions. That’s despite the growing number in the specialty, now counted at about 52,000.

The demand may be due to the fact that many hospitalists are leaving clinical work after 15-20 years, a trend less true with other medical specialties, Dr. Wachter said. “I’m hearing 50-year-old hospitalists say, ‘I need to leave; I can’t do this clinical work anymore. I’m going to be a consultant or a chief medical officer,” or take another administrative or consulting opportunity.

“You don’t want people to feel like they have to find something else if they’re really good doctors,” he said, as it would mean “throwing all that experience and training out the window” in midcareer.

When asked if hospitalists make more errors or put patient safety at risk on the 6th or 7th day of a schedule, Dr. Wachter referred to a study that revealed that when hospitalists get more than 15 patients on a census, costs and lengths of stay go up. “No one knew [before that study] whether 15 was the right number, and I think the same is true here,” he said. Dr. Wachter urged researchers to “study alternative models to see whether we can come up with one that is more sustainable,” and also to conduct appropriate studies with other models to see if error rates are different.

Dr. Wachter said during the phone interview that, as the hospitalist movement was beginning 20 years ago, the 7/7 model was derived from one used by the closest medical specialty to the hospitalist practice, emergency medicine. ED physicians adopted a model closer to 10- to 12-hour shifts every other day, 15 shifts a month.

Because continuity of care was the hospitalists’ goal, that schedule wouldn’t work, Dr. Wachter said. But 7 days of 12-hour shifts would, alternating through the 52 weeks of a year.

In addition, the 7/7 schedule was appealing to young hospitalists entering practice after residency. “Because wow, what a great thing! I work 12 hours a day, 7 days, and then I have a whole week off. What could be better for a younger doctor?” Dr. Wachter said. “But while there may be some 60-year-olds keeping to this schedule and things are fine, I don’t believe this is a viable schedule for a 60-year-old.”

Dr. John Nelson, the cofounder of the Society of Hospital Medicine and a hospital consultant in Bellevue, Wash., said he and Dr. Wachter agreed on this issue.

To a young doctor, the 7/7 schedule “sounds sweet,” but they don’t realize that “you have to shut your life down altogether for a week. What other job requires you to do that? It’s unreasonable,” Dr. Nelson said. The 7/7 schedule “does not promote career longevity,” he added.

Increasingly, Dr. Nelson said “countless” hospitalists tell him: “My 6th or 7th day in a row of work, I’m not really much on top of my game. I’m often less willing to sit and talk with a family as long.” The other issue, he said, is that as doctors get older, they find it difficult to fill their entire 7 days off productively.

So what’s the solution? Dr. Wachter and Dr. Nelson said they aren’t sure. But Dr. Nelson said the holy grail, which is maximizing the number of days off, should be changed. “Pursuit of the maximum number of days off is backfiring, failing to see the big picture,” he said. Rather hospitalists should work more days, but fewer hours.

“Most of us will be happier tending to work more days rather than fewer,” Dr. Nelson said. “You’ll get out to your kids’ soccer game at 4 o’clock in the afternoon, things like that. And you won’t drive into work with a knot in your stomach wondering how you’re going to survive 12 brutal hours.”

SAN DIEGO – The time has come to do away with the 12-hours-a-day, “7-on, 7-off” schedules followed by nearly all hospitalist groups, according to Dr. Robert Wachter, professor of medicine at the University of California, San Francisco, and father of the hospitalist movement.

To institutionalize such a schedule so broadly in the specialty’s earliest years “was a mistake, a well-meaning, understandable mistake … [but now] it feels like a real error that probably needs to be rethought,” Dr. Wachter said in his closing address at the Society of Hospital Medicine’s annual conference. The model is “fine for a 35-year-old,” he said, “but not so doable for a 55-year-old.”

In a follow-up phone interview, Dr. Wachter explained he’s increasingly hearing “tales of burnout from hospitalists” who are not as young as they used to be. And while burnout is a problem plaguing several medical specialties, “when you drill down and try to understand the source, it sounds like [hospitalists] are running for the entire day for 12 hours, and doing it 7 days a week. I don’t know many 50-year-olds who can do that” in a building where patients are on many floors, he said, noting that hospitalized patients are sicker and more complex.

Dr. Wachter said the hospitalist model is now used by between 70% and 90% of the nation’s hospitals, which given the number of recruiting advertisements in journals, are having a hard time filling hospitalist positions. That’s despite the growing number in the specialty, now counted at about 52,000.

The demand may be due to the fact that many hospitalists are leaving clinical work after 15-20 years, a trend less true with other medical specialties, Dr. Wachter said. “I’m hearing 50-year-old hospitalists say, ‘I need to leave; I can’t do this clinical work anymore. I’m going to be a consultant or a chief medical officer,” or take another administrative or consulting opportunity.

“You don’t want people to feel like they have to find something else if they’re really good doctors,” he said, as it would mean “throwing all that experience and training out the window” in midcareer.

When asked if hospitalists make more errors or put patient safety at risk on the 6th or 7th day of a schedule, Dr. Wachter referred to a study that revealed that when hospitalists get more than 15 patients on a census, costs and lengths of stay go up. “No one knew [before that study] whether 15 was the right number, and I think the same is true here,” he said. Dr. Wachter urged researchers to “study alternative models to see whether we can come up with one that is more sustainable,” and also to conduct appropriate studies with other models to see if error rates are different.

Dr. Wachter said during the phone interview that, as the hospitalist movement was beginning 20 years ago, the 7/7 model was derived from one used by the closest medical specialty to the hospitalist practice, emergency medicine. ED physicians adopted a model closer to 10- to 12-hour shifts every other day, 15 shifts a month.

Because continuity of care was the hospitalists’ goal, that schedule wouldn’t work, Dr. Wachter said. But 7 days of 12-hour shifts would, alternating through the 52 weeks of a year.

In addition, the 7/7 schedule was appealing to young hospitalists entering practice after residency. “Because wow, what a great thing! I work 12 hours a day, 7 days, and then I have a whole week off. What could be better for a younger doctor?” Dr. Wachter said. “But while there may be some 60-year-olds keeping to this schedule and things are fine, I don’t believe this is a viable schedule for a 60-year-old.”

Dr. John Nelson, the cofounder of the Society of Hospital Medicine and a hospital consultant in Bellevue, Wash., said he and Dr. Wachter agreed on this issue.

To a young doctor, the 7/7 schedule “sounds sweet,” but they don’t realize that “you have to shut your life down altogether for a week. What other job requires you to do that? It’s unreasonable,” Dr. Nelson said. The 7/7 schedule “does not promote career longevity,” he added.

Increasingly, Dr. Nelson said “countless” hospitalists tell him: “My 6th or 7th day in a row of work, I’m not really much on top of my game. I’m often less willing to sit and talk with a family as long.” The other issue, he said, is that as doctors get older, they find it difficult to fill their entire 7 days off productively.

So what’s the solution? Dr. Wachter and Dr. Nelson said they aren’t sure. But Dr. Nelson said the holy grail, which is maximizing the number of days off, should be changed. “Pursuit of the maximum number of days off is backfiring, failing to see the big picture,” he said. Rather hospitalists should work more days, but fewer hours.

“Most of us will be happier tending to work more days rather than fewer,” Dr. Nelson said. “You’ll get out to your kids’ soccer game at 4 o’clock in the afternoon, things like that. And you won’t drive into work with a knot in your stomach wondering how you’re going to survive 12 brutal hours.”

SAN DIEGO – The time has come to do away with the 12-hours-a-day, “7-on, 7-off” schedules followed by nearly all hospitalist groups, according to Dr. Robert Wachter, professor of medicine at the University of California, San Francisco, and father of the hospitalist movement.

To institutionalize such a schedule so broadly in the specialty’s earliest years “was a mistake, a well-meaning, understandable mistake … [but now] it feels like a real error that probably needs to be rethought,” Dr. Wachter said in his closing address at the Society of Hospital Medicine’s annual conference. The model is “fine for a 35-year-old,” he said, “but not so doable for a 55-year-old.”

In a follow-up phone interview, Dr. Wachter explained he’s increasingly hearing “tales of burnout from hospitalists” who are not as young as they used to be. And while burnout is a problem plaguing several medical specialties, “when you drill down and try to understand the source, it sounds like [hospitalists] are running for the entire day for 12 hours, and doing it 7 days a week. I don’t know many 50-year-olds who can do that” in a building where patients are on many floors, he said, noting that hospitalized patients are sicker and more complex.

Dr. Wachter said the hospitalist model is now used by between 70% and 90% of the nation’s hospitals, which given the number of recruiting advertisements in journals, are having a hard time filling hospitalist positions. That’s despite the growing number in the specialty, now counted at about 52,000.

The demand may be due to the fact that many hospitalists are leaving clinical work after 15-20 years, a trend less true with other medical specialties, Dr. Wachter said. “I’m hearing 50-year-old hospitalists say, ‘I need to leave; I can’t do this clinical work anymore. I’m going to be a consultant or a chief medical officer,” or take another administrative or consulting opportunity.

“You don’t want people to feel like they have to find something else if they’re really good doctors,” he said, as it would mean “throwing all that experience and training out the window” in midcareer.

When asked if hospitalists make more errors or put patient safety at risk on the 6th or 7th day of a schedule, Dr. Wachter referred to a study that revealed that when hospitalists get more than 15 patients on a census, costs and lengths of stay go up. “No one knew [before that study] whether 15 was the right number, and I think the same is true here,” he said. Dr. Wachter urged researchers to “study alternative models to see whether we can come up with one that is more sustainable,” and also to conduct appropriate studies with other models to see if error rates are different.

Dr. Wachter said during the phone interview that, as the hospitalist movement was beginning 20 years ago, the 7/7 model was derived from one used by the closest medical specialty to the hospitalist practice, emergency medicine. ED physicians adopted a model closer to 10- to 12-hour shifts every other day, 15 shifts a month.

Because continuity of care was the hospitalists’ goal, that schedule wouldn’t work, Dr. Wachter said. But 7 days of 12-hour shifts would, alternating through the 52 weeks of a year.

In addition, the 7/7 schedule was appealing to young hospitalists entering practice after residency. “Because wow, what a great thing! I work 12 hours a day, 7 days, and then I have a whole week off. What could be better for a younger doctor?” Dr. Wachter said. “But while there may be some 60-year-olds keeping to this schedule and things are fine, I don’t believe this is a viable schedule for a 60-year-old.”

Dr. John Nelson, the cofounder of the Society of Hospital Medicine and a hospital consultant in Bellevue, Wash., said he and Dr. Wachter agreed on this issue.

To a young doctor, the 7/7 schedule “sounds sweet,” but they don’t realize that “you have to shut your life down altogether for a week. What other job requires you to do that? It’s unreasonable,” Dr. Nelson said. The 7/7 schedule “does not promote career longevity,” he added.

Increasingly, Dr. Nelson said “countless” hospitalists tell him: “My 6th or 7th day in a row of work, I’m not really much on top of my game. I’m often less willing to sit and talk with a family as long.” The other issue, he said, is that as doctors get older, they find it difficult to fill their entire 7 days off productively.

So what’s the solution? Dr. Wachter and Dr. Nelson said they aren’t sure. But Dr. Nelson said the holy grail, which is maximizing the number of days off, should be changed. “Pursuit of the maximum number of days off is backfiring, failing to see the big picture,” he said. Rather hospitalists should work more days, but fewer hours.

“Most of us will be happier tending to work more days rather than fewer,” Dr. Nelson said. “You’ll get out to your kids’ soccer game at 4 o’clock in the afternoon, things like that. And you won’t drive into work with a knot in your stomach wondering how you’re going to survive 12 brutal hours.”

SAN DIEGO – Difficult patients, demanding families. What is your hospitalist team’s solution to dealing with the stress of managing difficult people and tense situations?

The toll that difficult patients take on hospitalists, nurses, and other doctors trying to provide appropriate care and appropriate discharge most certainly contributes to high rates of burnout, Dr. John Nelson said at the annual meeting of the Society of Hospital Medicine.

“The way it works now, all over our hospitals, we say ‘Yeah, you got that tough patient. Yup. Sorry. Hang in there’,” he said. Instead we need a team approach, a way “to provide care for these patients without undue stress and stomach churning, crying and anger, and fear for our safety” so that the patient gets appropriate care and careers aren’t adversely affected.

In his presentation, “Think Different: A New Approach to High-Cost, Low-Quality Care Provided to High-Utilizer Patients,” Dr. Nelson discussed the problems faced by hospitalists and hospital staffs trying to manage patients who argue with providers about pain medication, or their family members who “are so upset that the CT scan wasn’t done when promised.”

Then there are the patients with severe behavioral or mental health issues, who “hit and throw things. … I don’t think it’s ideal to say, ‘You go in there and take care of that person or call security.’ ”

These are patients who “can chew up 2 hours of your morning when you’ve got 19 patients to round on and the ED has started calling,” said Dr. Nelson of Overlake Hospital Medical Center in Bellevue, Wash.

The response to these exceptionally problematic patients happens “on sort of an ad hoc basis,” he said. “Emails go around. … ‘Tomorrow morning, we’re going to try to have a care conference about this patient. Can you come? Can you come?’ ... It’s a terrible stream of emails, [and] all these things are so vague that it limits our success.”

One alternative might be to designate a special team to get the data, intervene, and resolve whatever it is that has made the relationship “go off the rails,” he said. This rapid response team might be composed of the ED doctor, coordinators, social workers, psychiatrists, a nurse on the unit, the primary care doctor if available, and others – about 10 people, any 6 of whom would intervene in managing the difficult patient.

Dr. Nelson said he didn’t know what such a team would cost, nor was he aware of any other health care organization that had tried such a strategy.

The team Dr. Nelson said he envisions would develop templates of successful interventions. “Today, we try to fully customize a brand new completely special intervention for every patient. … I think that’s very hard … and we’re not going to be successful trying to do that one-off every time, and reinvent it every time.”

Rather, the response team would develop a menu of interventions appropriate to the situation. One might be that the CEO is sent in to apologize. Another might be placing security stands at the door, or escorting combative family members off the campus. Another might be to develop a behavior contract that the patient signs. Maybe the patient’s expectation can be reasonably met.

Once the team members have gone through various interventions, they can determine which ones work and develop “a much less distressing, much more well-organized approach to responding to these kinds of patients,” Dr. Nelson said.

Staff and physicians should not go home “worried they’re going to be sued, or dreading returning to work the next day because they’re going to have to face this very, very difficult family, and no one is really helping,” he said.

SAN DIEGO – Difficult patients, demanding families. What is your hospitalist team’s solution to dealing with the stress of managing difficult people and tense situations?

The toll that difficult patients take on hospitalists, nurses, and other doctors trying to provide appropriate care and appropriate discharge most certainly contributes to high rates of burnout, Dr. John Nelson said at the annual meeting of the Society of Hospital Medicine.

“The way it works now, all over our hospitals, we say ‘Yeah, you got that tough patient. Yup. Sorry. Hang in there’,” he said. Instead we need a team approach, a way “to provide care for these patients without undue stress and stomach churning, crying and anger, and fear for our safety” so that the patient gets appropriate care and careers aren’t adversely affected.

In his presentation, “Think Different: A New Approach to High-Cost, Low-Quality Care Provided to High-Utilizer Patients,” Dr. Nelson discussed the problems faced by hospitalists and hospital staffs trying to manage patients who argue with providers about pain medication, or their family members who “are so upset that the CT scan wasn’t done when promised.”

Then there are the patients with severe behavioral or mental health issues, who “hit and throw things. … I don’t think it’s ideal to say, ‘You go in there and take care of that person or call security.’ ”

These are patients who “can chew up 2 hours of your morning when you’ve got 19 patients to round on and the ED has started calling,” said Dr. Nelson of Overlake Hospital Medical Center in Bellevue, Wash.

The response to these exceptionally problematic patients happens “on sort of an ad hoc basis,” he said. “Emails go around. … ‘Tomorrow morning, we’re going to try to have a care conference about this patient. Can you come? Can you come?’ ... It’s a terrible stream of emails, [and] all these things are so vague that it limits our success.”

One alternative might be to designate a special team to get the data, intervene, and resolve whatever it is that has made the relationship “go off the rails,” he said. This rapid response team might be composed of the ED doctor, coordinators, social workers, psychiatrists, a nurse on the unit, the primary care doctor if available, and others – about 10 people, any 6 of whom would intervene in managing the difficult patient.

Dr. Nelson said he didn’t know what such a team would cost, nor was he aware of any other health care organization that had tried such a strategy.

The team Dr. Nelson said he envisions would develop templates of successful interventions. “Today, we try to fully customize a brand new completely special intervention for every patient. … I think that’s very hard … and we’re not going to be successful trying to do that one-off every time, and reinvent it every time.”

Rather, the response team would develop a menu of interventions appropriate to the situation. One might be that the CEO is sent in to apologize. Another might be placing security stands at the door, or escorting combative family members off the campus. Another might be to develop a behavior contract that the patient signs. Maybe the patient’s expectation can be reasonably met.

Once the team members have gone through various interventions, they can determine which ones work and develop “a much less distressing, much more well-organized approach to responding to these kinds of patients,” Dr. Nelson said.

Staff and physicians should not go home “worried they’re going to be sued, or dreading returning to work the next day because they’re going to have to face this very, very difficult family, and no one is really helping,” he said.

SAN DIEGO – Difficult patients, demanding families. What is your hospitalist team’s solution to dealing with the stress of managing difficult people and tense situations?

The toll that difficult patients take on hospitalists, nurses, and other doctors trying to provide appropriate care and appropriate discharge most certainly contributes to high rates of burnout, Dr. John Nelson said at the annual meeting of the Society of Hospital Medicine.

“The way it works now, all over our hospitals, we say ‘Yeah, you got that tough patient. Yup. Sorry. Hang in there’,” he said. Instead we need a team approach, a way “to provide care for these patients without undue stress and stomach churning, crying and anger, and fear for our safety” so that the patient gets appropriate care and careers aren’t adversely affected.

In his presentation, “Think Different: A New Approach to High-Cost, Low-Quality Care Provided to High-Utilizer Patients,” Dr. Nelson discussed the problems faced by hospitalists and hospital staffs trying to manage patients who argue with providers about pain medication, or their family members who “are so upset that the CT scan wasn’t done when promised.”

Then there are the patients with severe behavioral or mental health issues, who “hit and throw things. … I don’t think it’s ideal to say, ‘You go in there and take care of that person or call security.’ ”

These are patients who “can chew up 2 hours of your morning when you’ve got 19 patients to round on and the ED has started calling,” said Dr. Nelson of Overlake Hospital Medical Center in Bellevue, Wash.

The response to these exceptionally problematic patients happens “on sort of an ad hoc basis,” he said. “Emails go around. … ‘Tomorrow morning, we’re going to try to have a care conference about this patient. Can you come? Can you come?’ ... It’s a terrible stream of emails, [and] all these things are so vague that it limits our success.”

One alternative might be to designate a special team to get the data, intervene, and resolve whatever it is that has made the relationship “go off the rails,” he said. This rapid response team might be composed of the ED doctor, coordinators, social workers, psychiatrists, a nurse on the unit, the primary care doctor if available, and others – about 10 people, any 6 of whom would intervene in managing the difficult patient.

Dr. Nelson said he didn’t know what such a team would cost, nor was he aware of any other health care organization that had tried such a strategy.

The team Dr. Nelson said he envisions would develop templates of successful interventions. “Today, we try to fully customize a brand new completely special intervention for every patient. … I think that’s very hard … and we’re not going to be successful trying to do that one-off every time, and reinvent it every time.”

Rather, the response team would develop a menu of interventions appropriate to the situation. One might be that the CEO is sent in to apologize. Another might be placing security stands at the door, or escorting combative family members off the campus. Another might be to develop a behavior contract that the patient signs. Maybe the patient’s expectation can be reasonably met.

Once the team members have gone through various interventions, they can determine which ones work and develop “a much less distressing, much more well-organized approach to responding to these kinds of patients,” Dr. Nelson said.

Staff and physicians should not go home “worried they’re going to be sued, or dreading returning to work the next day because they’re going to have to face this very, very difficult family, and no one is really helping,” he said.