Richard Quinn

Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

Thadeo Catacutan, MD, sat in a ballroom at the Gaylord Resort & Convention Center in National Harbor, Md., on a sunny spring day at HM13, just thinking about his future after spending seven years as a hospitalist at Cleveland Clinic. He wondered if additional training in business administration would provide him with the advancement opportunities and professional fulfillment he sought.

“It’s been hard to determine what I really want to do,” he said. “After seven years, is this the peak? Are there other opportunities?

“I realize that if you are not going to specialize, you have to go into a leadership career track,” he said. “Some would say you can just be a clinician, but in the long term, I don’t think that is a sustainable path. You will just burn out.”

Dr. Catacutan isn’t the only one concerned. Nearly 200 physicians joined him for an HM13 breakout session titled “Career Tracks for Hospitalists.” The session provided attendees two viewpoints on career advancement: the executive pathway and the hospital leadership pathway. And although the session’s speakers demonstrated distinct routes to senior positions, there’s a shared path for each, including:

• Weighing choices carefully. The reasons for seeking a new career path are personal and not the same for everyone. Keep that in mind.
• Thinking about return on investment. Physicians should consider what they’re getting for their effort, whether that’s the cost of an advanced degree or the value of time spent volunteering on a hospital committee.
• Contemplating what you like about your job. When considering a career move, remember the adage that the grass is always greener.

“The way you get to take on leadership opportunities is by acceptance,” said session moderator Michael Guthrie, MD, MBA, executive in residence at the University of Colorado. “Say ‘yes.’ Say ‘I’m curious’ or ‘How can I make a contribution?’ You will stumble. You will make mistakes. You will be clumsy. … But it is that process that teaches you what you need to know.”

Path: Advanced Training

Michael Ruhlen, MD, MHCM, FACHE, SFHM, said he needed to know how to communicate better with the administrators he regularly met with to discuss his pediatric hospitalist program.

“I found that I wasn’t always speaking the same language when I talked to administrators about the value that hospitalists brought to their individual institutions,” he said. “No matter how hard I tried, I could always walk into a room with a master’s-prepared administrator who could absolutely prove to me that my hospitalist program would cost them far more money than it would ever be worth—and they simply could not afford it.”

To address what he calls a “knowledge deficit,” Dr. Ruhlen earned his master’s degree in health-care management from the Harvard School of Public Health in Boston. Armed with new business acumen, he rose to vice president of medical affairs at Toledo Children’s Hospital in Ohio, and even served as interim president for a short time before he became vice president and chief medical officer of Carolina HealthCare Systems in Charlotte, N.C.

“Communications, public speaking, and change management was a very big component of what we were taught,” he added, “as well as performance improvement, which is where my career has drifted.”

Dr. Ruhlen said hospitalists are perfectly positioned for leadership roles in hospitals. He also said that “institutions led by physicians appear to have better performance metrics” and that physicians “owe it to our patients to try to take back medicine.”

One thing Dr. Ruhlen wished medical training would address better is population health, a topic he became “enamored” with in business school. “It’s a very interesting body of work, interesting body of language,” he said. “I think it will be critically important as we move into a realm of significant health reform.”

Path: Quality Expertise

Greg Maynard, MD, MSC, SFHM, took a different route to hospital leadership. He didn’t seek an advanced degree in business and hasn’t bounced from one job to another climbing the corporate ladder. Instead, he’s devoted his time and energy to quality improvement (QI) as clinical professor of medicine in the division of hospital medicine at the University of California at San Diego.

Dr. Maynard encouraged hospitalists to consider becoming experts in hospital quality and patient safety, a path that has led him to national recognition. “You won’t get bored,” he said. “Your career will find you.”

Dr. Maynard, who serves as senior vice president of SHM’s Center for Healthcare Improvement and Innovation, said every QI project “seems to have its time,” and he warned hospitalists that dealing with frustration is part of the job description.

“Some projects I initiated didn’t get off the ground, no matter why I did it,” he explained. “For example, transitions of care—when we started looking at it, nobody in the hospital cared. The administrators didn’t care about discharge summaries or teachback communication strategies. They only cared when readmissions came in focus.”

He and his team needed to learn to “satisfy ourselves” and change what they could change as hospitalists. The hard part, he said, was being patient.

“We knew it was coming; we just had to wait and not get rankled,” he added. “I had to learn to not take things personally. Be patient and wait for the opportunity.”

Dr. Maynard advised hospitalists to learn to “say no, or ‘I would love to but I just can’t.’” He also said hospitalists should not be afraid to ask for help.

Return on Investment

Dr. Guthrie, who received his MBA nearly 40 years ago, said times have changed and business schools have adapted to a new economic landscape. Opportunities for physicians to receive advanced training are much greater now, with physicians earning advanced degrees in public health and health administration, as well as MBAs.

Many of the top schools offer work-friendly course schedules, including night and weekend courses and plenty of online options. Some, such as the University of Massachusetts, offer a 100% online MBA program.

Listen to Dr. Guthrie discuss his path to hospital leadership and how business schools have adapted for physicians.

Still, he warned hospitalists to consider their goals along with the time, energy, and financial commitment that post-graduate work requires.

“The investment is huge,” he said.

It’s exactly what Dr. Catacutan is contemplating. Should he go back to school, pursue leadership within the walls of his hospital and executive courses like SHM’s Leadership Academy, or should he be satisfied as a full-time clinician?

“Is it really worth my time, especially with family and kids?” he asked rhetorically. “It’s a personal decision.” TH

Richard Quinn is a freelance writer in New Jersey.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

A new study shows that hospitalized patients who were more engaged in their own care produced higher costs and longer lengths of stay (LOS).

The report, "Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients," published in JAMA Internal Medicine, used a survey of 21,754 patients in one academic setting to determine their preferences on shared decision-making. The information was later linked to administrative data.

Patients who said they preferred to participate in decision-making with their physicians had a 0.26-day (95% CI, 0.06-0.47 day) longer LOS (P=0.01) and incurred an average of $865 (95% CI, $155-$1,575) in higher total hospitalization costs (P=0.02). Patients with higher education levels and private health insurance were more likely than others to want to participate in decision-making with doctors, the authors noted.

Lead author Hyo Jung Tak, PhD, of the department of medicine at the University of Chicago says that while the results don't mean that patient-centered care directly drives up costs, it is important not to accept at face value that engaged patients lead to reduced health-care-delivery costs.

“These days,” she adds, “many researchers and policymakers expect that patient-centered care could help to reduce medical utilization as it could prevent costly interventions that patients may not want, but I think people should be more careful in terms of how it really applies in the clinical setting.”

Dr. Tak cautions that many variables could affect how a similar study would work at other hospitals, including an institution’s payor mix and the socioeconomic status of its service area. She said a potentially larger issue is why some patients strongly disagree with the idea of leaving medical decisions up to their physicians.

“If we can find that answer, that could help to improve patient-centered care in the future,” Dr. Tak adds. “That could be the ultimate question in this study.”

Visit our website for more information on patient-centered care.

Click here to

listen to Dr. Hecht

Click here to

listen to Dr. Hecht

Click here to

listen to Dr. Hecht

Click here to listen to Dr. Rosen.

Click here to listen to Dr. Rosen.

Click here to listen to Dr. Rosen.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.

Many hospitalists are anxious about looming changes to the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) process, but hospital medicine leaders say the effect will be positive.

In January, ABIM and the American Board of Medical Specialties (ABMS) will begin reporting on whether hospitalists and other physicians are meeting MOC requirements. To do so, physicians need to complete 20 ABIM MOC points by December 2015, and every two years after that. Physicians also need to earn 100 ABIM MOC points by December 2018, and every five years after that.

Previously, physicians had to amass a total of 100 points every 10 years between secure exams. The new rules are aimed at keeping “pace with the changes in the science of medicine and assessment,” ABIM says on its website.

“I think the anxiety is coming out of it being misunderstood,” says Jeff Wiese, MD, MHM, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans. “It’s not that big of a deal when you put it in the context of what you do for CME now.”

Dr. Wiese emphasizes the secure exam will still be taken every 10 years, but increasing the frequency of learning via practice-improvement modules (PIMs) and other vehicles should serve to improve hospitalists’ efficiency and care delivery.

Ethan Cumbler, MD, FACP, of the University of Colorado at Denver, an annual faculty member for the ABIM’s MOC pre-course at SHM’s annual meetings, says that codifying additional learning is a good thing for the specialty. “If the point of this is to actually improve how we’re practicing as doctors, then we do want to be practicing this in an ongoing fashion,” Dr. Cumbler says.

Visit our website for more information on CME.

Click here to listen to new SHM President Eric Howell

Click here to listen to new SHM President Eric Howell

Click here to listen to new SHM President Eric Howell

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.