The Hospitalist

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

Not much intimidates Jasen Gundersen, MD, president of the acute care services division at TeamHealth, an outsourcer of hospital-based clinical and specialty services based in Knoxville, Tenn. Besides traveling 150,000 miles a year overseeing 2,500 hospitalists at 285 facilities, Dr. Gundersen has climbed frozen waterfalls in Vermont and New Hampshire, raced in bicycle competitions, and skied mountains towering 10,000 feet.

But his love for adventure is now focused below the surface. Over the years, he has spent many weekends diving in open waters surrounding southeast Florida; Cozumel, Mexico; Turks and Caicos; and the Cayman Islands. He believes there’s no place on Earth that is as peaceful, serene, or even magical as under the ocean.

Reclaimed Passion

Growing up in Connecticut, Dr. Gundersen and his family frequently vacationed in the Bahamas, where he was introduced to scuba diving.

“As a teenager, I really loved diving,” he recalls. “Every time we went to the Bahamas, I always tried to go diving or snorkeling.”

However, the harsh Connecticut winters and frigid Atlantic Ocean prevented him from diving. More delays followed, namely medical school. After graduating from the University of Connecticut School of Medicine in 2000, Dr. Gundersen completed his three-year residency in family medicine at the UMass Memorial Medical Center. During the next two years, he worked as a physician and hospitalist at the Family Health Center of Worcester, a federally qualified health center where he did everything from examining sore throats to delivering babies.

In 2005, he launched a small hospital medicine program at the University of Massachusetts that quickly grew and bumped up his title to division chief for hospital medicine. Then in January 2011, he accepted a new position as chief medical officer at TeamHealth, requiring him and his wife, Elizabeth, also a hospitalist, to move to Florida.

Within several weeks, the couple started diving near their home in Pompano Beach. He says Elizabeth, his “diving buddy,” was eager to learn and developed a passion for scuba diving that rivals his own.

“We did 80 to 90 dives in the first year we were down there,” Dr. Gundersen says, explaining that unlike many sports, diving doesn’t require athletic ability, size, or strength. “We normally did recreational diving, where you basically can always swim slowly straight to the surface. You don’t stay down long enough that you build up enough bubbles in your system that you have to stop on the way up.”

Sharks and Shipwrecks

Since then, Dr. Gundersen purchased a 38-foot powerboat, became a PADI (Professional Association of Diving Instructors) open-water scuba instructor, and earned a U.S. Coast Guard 50-ton master captain’s license. He and Elizabeth are certified for advanced nitrox and decompression diving, technical diving that requires the use of different gases to decompress when heading to the surface, and diving in overhead environments, such as caves or shipwrecks.

“One of our favorite wrecks is called the USS Spiegel Gove that sits on the ocean floor in Key Largo,” he says, adding that on occasion, they also swim with hammerhead sharks. “The walls of the ship go 30 feet up on each side. You can swim where they loaded the cargo and see the old crane above you. It’s spectacular.”

Among their favorite spots to dive is Eagle Ray Pass in Grand Cayman, where entire schools of spotted eagle rays live, he says, adding that 17 rays swam and floated around them during one dive.

Fortunately, after some initial costs, he says the sport isn’t too expensive, roughly around $1,500 to get started. Basic scuba gear costs approximately $1,000. Likewise, certifications can run $350 a piece. Boat trips range between $60 and $100, unless you prefer shore diving, where you park at the beach and simply swim into the ocean. Then add a few extra dollars to fill your tank with air.

Scary and Serene

Although the Gundersens are accomplished divers who prefer warm waters and flat seas, Dr. Gundersen says only one moment of one dive actually scared him.

Years ago, he, Elizabeth, and a friend were wreck diving. Diving protocol is based on follow the leader, where divers swim into wrecks one at a time, follow each other, and signal their turns. Somehow, their friend unintentionally swam in between Dr. Gundersen and his wife. Elizabeth and the friend then turned to see something inside the wreck, but the friend failed to signal to Dr. Gundersen that they were turning.

“I went a bit farther and turned around,” Dr. Gundersen recalls. “He and Elizabeth were gone. It gave me a moment of panic. I’m particularly careful about staying with my diving buddy and making sure we don’t get lost. It wasn’t dangerous but broke the cardinal rule of what you’re supposed to do when diving. I swam back and found them.”

While that was a rare experience, he says diving, when done properly, is the most peaceful and serene activity that people may experience. When under water, all you hear are your air bubbles. There are no cellphones ringing, emails or texts to respond to, or work issues to resolve.

“Work-life balance is a really big deal for me and my team to prevent burnout,” Dr. Gundersen says. “It allows me to have my personal time to enjoy and relax so when I’m back at work on Monday, my batteries are recharged. I’m ready to go.” TH

Carol Patton is a freelance writer in Las Vegas.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

To promote achievable solutions in the ongoing debate on drug financing, Anthem, Inc. and Eli Lilly and Company are offering two policy proposals, which are detailed in “Discovering New Medicines and New Ways to Pay for Them,” published on the Health Affairs blog.

The first proposal calls for clarifying federal regulation to reduce perceived barriers impeding conversations between health benefit companies and biopharmaceutical companies about drugs prior to the drugs being approved for sale.

The second proposal calls for changes to federal laws and regulations to mitigate the barriers that make it difficult to move toward value-based contracting.

“A change in policies could open the door to new opportunities for hospitalists and their employers to create more high-value care,” says Sam Nussbaum, MD, Anthem clinical advisor. “Today, hospitals are paid for seeing patients. What if hospitals participated in a value-based arrangement with manufacturers and insurers that included treating patients with a specific condition with a new therapy proven to be more effective in producing better health outcomes, including keeping patients out of the hospital?”

Reference

1. Nussbaum S, Ricks D. Discovering new medicines and new ways to pay for them. Health Policy Lab. Available at: http://healthaffairs.org/blog/2016/01/29/discovering-new-medicines-and-new-ways-to-pay-for-them/. Accessed February 15, 2016.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.

Procedures are the most expensive item in healthcare, but tremendous variation remains in quality.

“In part that’ s because we have weak systems of peer support and in part because medicine sanctions a physician to do procedures, and then for the next 40 or 50 years, a surgeon can receive no input and not change their technique even though the field changes,” says Martin Makary, MD, MPH, professor of surgery and health policy and management at Johns Hopkins University in Baltimore.

Video could be used to address this, he suggests in an editorial called “Video Transparency: A Powerful Tool for Patient Safety and Quality Improvement” in the January 2016 BMJ Quality & Safety.

“In areas of excellence outside of medicine—football, aviation—they use video and video feedback for educational purposes. In healthcare, we can also use video to learn,” he says. “In surgical care, we can actually predict outcomes based on independent review of procedure video, but we just choose not to record videos because we don’ t have the infrastructure set up to provide feedback.”

When it has been done, he says, it’ s been received with enthusiasm. This doesn’ t mean cameras in primary-care clinics monitoring physicians.

“We’ re talking about the video-based procedures being recorded, not being erased with the next procedure that’ s done,” he says. “In the past, we couldn’ t do this with videotapes, but now with the capacity of memory and video data storage, there’ s an opportunity to leave the ‘ record’ button on on the video-based procedures that are already taking place.”

Reference

1. Joo S, Xu T, Makary MA. Video transparency: a powerful tool for patient safety and quality improvement [published online ahead of print January 12, 2016]. BMJ Qual Saf,doi:10.1136/bmjqs-2015-005058.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
3. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
3. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
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Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.

Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.

Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.