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Hospitalists Are the Vanguard of Care Shift, Experts Say


Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

Keynote speaker Dr. Morrison answers audience questions after his address April 5.

Keynote speaker Dr. Morrison answers audience questions after his address April 5.

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Dr. Wachter outlined six mega-trends he expects to affect hospital medicine.

Dr. Wachter outlined six “mega-trends” he expects to affect hospital medicine.

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

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