Over the past 20 years, hospitalists have served as the primary workforce for the clinical care of medical inpatients in the United States.^1,2 Core competencies¹ state that hospitalists should be able to perform the following bedside procedures: lumbar puncture, paracentesis, thoracentesis, arthrocentesis, and central venous catheter placement. More recently, standard of care has dictated that these procedures be performed under ultrasound guidance,^3-6 and thus hospitalists are also expected to be adept at point-of-care ultrasound (POCUS).⁷

However, no current national standard exists for ensuring basic competency among hospitalists performing bedside procedures. In addition, hospitalists’ procedural volumes are declining,^8,9 and standards for procedural training during internal medicine residency have been reduced.¹⁰ As a result, many residents who intend to become hospitalists are no longer prepared to perform these procedures.

The ramifications of the loss of procedural competency for hospitalists are manifold. Technical errors are a significant source of patient morbidity and mortality,^11-15 and complications arising specifically from nonoperative procedures range from 0 to 19%,¹⁶ although these data do not distinguish technical errors from unpreventable adverse events nor the degree to which hospitalists contributed to these complications. Second, hospitalists in academic medical centers might be ill equipped to function as supervisors of trainees performing procedures, which could perpetuate a cycle of suboptimal technical skills.¹⁷ Finally, the discrepancy between consensus guidelines for hospitalists and their scope of practice represents a significant area of risk management for institutions that base their credentialing policies on published competencies.

There are many compelling reasons for why hospitalists should maintain—in fact reclaim—a primary role in bedside procedures.¹⁸ Hospitalists in community and rural settings might not have easy access to procedural specialists. In academic institutions, hospitalists are the primary instructors and supervisors of procedures performed by internal medicine residents. The increased availability of POCUS allows formally trained hospitalists to perform procedures more safely under imaging guidance.¹⁶

The literature on procedures performed by hospitalists, although limited, has focused on POCUS, systems innovations such as medical procedure services (MPS), and policy recommendations for procedural credentialing. Most studies on effective procedural instructional approaches have been conducted among trainees, who are procedural novices. This research does not sufficiently address the dilemma that hospitalists face as independent physicians for whom procedures are not a significant component of their practice, yet are expected to perform invasive procedures occasionally. The purpose of our literature review is to synthesize the available research to characterize contributors to hospitalists’ procedural competency. We conclude with considerations for hospital medicine practice.

We performed a structured literature search for peer-reviewed articles related to hospitalists conducting procedures, being trained in procedures, or related to hospitalist-run MPS. We focused our search on the core hospitalist procedures with the highest potential morbidity (ie, lumbar puncture, abdominal paracentesis, thoracentesis, and central venous catheterization). We searched PubMed and Google Scholar for articles published since 1996 (when the term “hospitalists” was first coined) using keyword searches for [hospitalist OR hospital medicine] AND [procedur* OR medical procedur* OR medical procedure service] OR [(procedur* AND (train* OR educat* OR teach OR instruct*)] OR abdominal paracentes* OR thoracentes* OR lumbar puncture OR central venous catheter* OR ultrasound OR point-of-care. We included original research, brief research reports, perspectives, guidelines, and consensus statements. Exclusion criteria were articles that focused on nonhospitalists and conference abstracts. We used pearling to identify secondary sources from included articles’ bibliographies, without limits on year of publication.

Trends Towards Specialist Referrals

Between 1986 and 2007, the number and variety of procedures performed by internists decreased by half.¹⁹ Hospitalists still completed procedures in greater volume and variety than nonhospitalists,⁸ with approximately 50% of hospitalists performing lumbar punctures (50%), abdominal paracenteses (49%), and thoracenteses (44%) compared with less than 25% for all three procedures for nonhospitalists. Additionally, only 11% of surveyed hospitalists⁸ performed all nine core procedures, although these included procedures that are largely cognitive in nature (eg, electrocardiogram interpretation, chest X-ray interpretation) or procedures that have been relegated to other specialists (eg, endotracheal intubation, ventilator management, or joint injection/aspiration).

Surveys showed that, especially in larger cities and academic centers, procedural specialists have taken over a disproportionate share of procedures even as the number of procedures performed continued to rise.²⁰ Between 1993 and 2008, the number of paracenteses and thoracenteses increased by 133% and decreased by 14%, respectively, but the share of procedures performed by radiologists increased by 964% and 358%, respectively, as evident in an analysis of Medicare billing data.²⁰ A more recent study of Medicare claims from 2004 to 2016 similarly revealed that the percentage of paracenteses performed by radiologists compared with nonradiologists rose from 70% to 80% and thoracenteses from 47% to 66%, respectively.²¹ Comparable trends were apparent in claims data for lumbar punctures; between 1991 and 2011, the share of lumbar punctures performed by radiologists rose from 11% to 48%.²²

In academic medical centers, hospitalists might have the opportunity to pursue other activities (eg, education, administration, research) as they progress in their careers, resulting in less clinical activity. Although hospitalists who are more clinically active in hospital care tended to perform more procedures,⁸ those with smaller clinical footprints reported lower levels of comfort with performing procedures⁸ and might have less available time to maintain procedural competency or train in new technologies such as POCUS.¹⁷

Additionally, hospitalists in both academic and community settings cited efficiency as a major reason for procedural referral. Hospitalists tended to perform more procedures if they had fixed salaries or if less than 50% of their income was based on clinical productivity, although this trend was not significant.⁸ Further, they also might be motivated by competing opportunity costs such as time lost caring for other patients or length of shift, which influences the amount of time spent at work.²³

Notably, speculation that hospitalists referred more complex cases to specialists was not borne out by studies examining referral patterns.^21,24,25

Procedural Outcomes for Hospitalists vs Nonhospitalists

No convincing data exist that procedures performed by specialists have better outcomes than those completed at the bedside by well-trained generalists, although studies were limited to the inpatient setting, to generalists who have some exposure to procedures, and to internal medicine residents on inpatient rotations. In one retrospective review, interventional radiology (IR) referrals were associated with more platelet or plasma transfusions and intensive care unit transfers than those performed at the bedside by internal medicine residents, findings that remained significant after accounting for complexity (eg, Model for End-stage Liver Disease score, need for dialysis, and platelet count).²⁴ Similarly, a prospective audit of 529 bedside procedures did not show any differences in complication rates between generalists and pulmonologists, once generalists underwent standardized training and used pleural safety checklists and ultrasound guidance.²⁶ An administrative database review of 130,000 inpatient thoracenteses across several university hospitals between 2010 and 2013 found that the risk of iatrogenic pneumothorax was similar among operators from IR, medicine, and pulmonary (2.8%, 2.9%, and 3.1%, respectively)²⁷; these findings have been reproduced in other studies.²⁸ Finally, the increasing adoption of procedural ultrasound permits procedures to be conducted more safely at the bedside, without the need to refer to radiology for imaging guidance.^3-5

IR procedures also are associated with increased healthcare costs compared with bedside procedures. One study showed that hospital costs for admissions when paracenteses were performed by radiologists were higher than those in which the procedure was completed at the bedside by gastroenterologists or hepatologists.²⁵ A chart review examining 399 paracenteses, thoracenteses, and lumbar punctures found that the average procedure cost increased by 38% for referred procedures and 56% for radiology-performed procedures, as compared with bedside procedures.²⁹ Needing ancillary staffing in dedicated suites to perform procedures contributed to the excess cost.⁹ Moreover, referred procedures resulted in increased length of stay, which can incur additional costs. However, the data were conflicting; two studies did not show a statistical difference,^25,28 while others found an increased length of stay,^24,27,29 which might be due to the unavailability of specialists during off hours, thereby delaying nonemergent procedures.²¹ Detailed cost analyses have controlled for the use of procedural facilities and blood transfusions among IR specialists and simulation training among generalists, showing that total costs were $663 per patient undergoing IR procedures compared with $134 per patient undergoing bedside procedures.³⁰

Lack of Standardized Procedural Training or Assessment

A robust body of primary studies and systematic reviews supports the use of simulation for procedural training to improve comfort and skill as well as reduce complication rates and costs.^31,32 A systematic review that investigated the impact of four paradigms of procedural training found that MPS and quality improvement/patient safety approaches led to the most active learning compared with apprenticeship (ie, “see one, do one”) and approaches based on educational theories.³³ Nevertheless, the vast majority of the research has been conducted in trainees,^32,34 with sparse evidence among practicing physicians. One cohort study of attending physicians’ central venous catheter insertion skills on simulators found low and variable short-term performance, showing overall poor adherence to checklists.³⁵ One article suggested that hospitalists’ procedural skills were below established thresholds of competency at baseline and that simulation-based training did not result in sustained skills, but the small sample size and high attrition limited meaningful conclusions.³⁶ Although continuing medical education courses are available to hospitalists, there is no published evidence supporting their effectiveness.

Proxies for procedural skill have included comfort and experience, yet these markers have broadly been shown to be inadequate.^34,36,37 Additionally, the natural decline of skill over time has invoked the need for periodic reassessment of proficiency.^36,38 Credentialing has been equally inconstant; a survey of the Society of Hospital Medicine’s (SHM) POCUS task force revealed that only half of respondents reported their hospitals required a minimum number of procedures for initial credentialing and recredentialing.³⁹ In short, periodic assessment of procedural skills among hospitalists has not been a routine process at many institutions.

Role of Hospitalist-Run Medical Procedure Services

It might not be necessary for all hospitalists to be proficient and credentialed in a given procedure,¹ and a trend has emerged in the creation of MPS staffed by hospitalists as proceduralists. The primary aim of these MPS has been to recapture the procedures—and associated revenue—that would otherwise be referred to specialists. Moreover, concentrating procedures among a core group of hospitalists endeavors to support patient safety through several principles: (1) to increase technical proficiency through higher procedural volumes, (2) to facilitate rigorous training and assessment among dedicated individuals, and (3) to systematize best practices of operator performance, communication, and documentation.

MPS have been implemented around the country and have demonstrated several advantages. In one institution, medical firms that were offered the use of an MPS had 48% more procedural attempts by nonspecialists, without significant differences in the proportions of successful attempts or complications compared with the firms who more often referred to specialists.⁴⁰ A retrospective study analyzed outcomes of 1,707 bedside procedures, of which 548 were performed by an MPS, and found that procedures done by the MPS were more likely to result in lower rates of unsuccessful procedures and to use best-practice safety processes (ie, to involve attending physicians, to use ultrasound guidance, and to avoid femoral sites for catheterization).¹² Satisfaction was high among patients who underwent bedside procedures performed by a hospitalist-supervised, intern-based procedure service with a focus on bedside communication.⁴¹ From a workforce perspective, MPS have also allowed surgical or radiological subspecialties to focus on more complex cases with higher reimbursement rates,^18,42 for proceduralists to expand beyond core procedures (eg, bone marrow biopsies⁴³), and to train advanced practice providers.⁴⁴ Although studies have not shown that the outcomes of procedures completed by an MPS are better than the outcomes of procedures performed by other specialists,⁴⁵ one can potentially extrapolate from earlier data that procedures done at the bedside by nonradiologists would have comparable outcomes.

A myriad of factors is influencing hospitalists’ scope of practice with respect to bedside procedures. Some evidence suggests that procedures performed by specialists are not superior to those done by generalists and might be associated with increased costs. The most promising developments in the past few decades include simulation-based training, which has demonstrated effectiveness across an array of clinical outcomes but has not been sufficiently evaluated in hospitalists to draw conclusions, and hospitalist-led MPS, which promote safe and productive procedural clinical practices. However, decreasing procedural volume, increasing referrals to specialists, dwindling hospitalist interest and/or confidence, time constraints, limited training opportunities, nonuniform credentialing policies, and lack of standardized assessment are cumulatively contributing to a loss of procedural competency among hospitalists.

Taken together, these forces should compel hospital medicine groups that expect their hospitalists to perform their own procedures to identify necessary steps for ensuring the safety of hospitalized patients under their care. The following considerations derive from the available—albeit modest—evidence on procedural performance in hospital medicine (Table).

1. Create MPS to establish a core set of hospitalists to perform procedures and train them using evidence-based practices. Creation of an MPS places the responsibility of core bedside procedures in the hands of a select group of proceduralists. This strategy streamlines training and assessment of individual procedural competency to meet standards set by SHM^36,46 and improves educational outcomes.^47-49 MPS could improve clinical outcomes,^12,42,50-52 including length of stay and cost, while maintaining patient satisfaction,⁴¹ as well as recoup lost revenue from referrals by increasing the volume of procedures done by generalists,^40,49 although no robust data supporting the latter point exists. Implementing an MPS requires full-time equivalent (FTE) support for proceduralists and administrative support for data collection and tracking complications. Furthermore, a well-functioning MPS will require investment in portable ultrasound machines and training in POCUS, which has been shown to decrease complications and increase success of invasive bedside procedures.^3-7 Hospital medicine groups should be aware that staffing an MPS can divert hospitalist labor and resources from other needed clinical areas, especially during the initial, low-volume phases of implementation. Strategies to offset relative value unit (RVU) loss include combining the MPS with existing clinical roles such as medical consults, code triage, and rapid response teams; or with services with lower patient caps, which might work particularly well in community hospitals. In many institutions, hospitalists can bill for procedural consults in addition to the procedures when the consult involves nonmedical patients, which is relevant when the procedure ultimately cannot be performed (eg, too little ascites to safely perform a paracentesis). Further research should establish best practices of MPS to ensure maximum procedural productivity and safety, because there are no rigorous prospective studies that evaluate strategies to create this service. Such strategies include determining the optimal ratio of proceduralists to general hospitalists, hospital characteristics that benefit most from MPS (eg, referral centers, urban-based settings), volume and type of procedures performed, and the proportion and type of referrals that are most cost-effective.

2. Establish policies with procedural specialists to arrange coverage for off-hours procedures and delineate thresholds for procedures that specialists should perform. Expanding hospitalists’ capabilities in performing procedures should trigger reconsideration of the medical center’s approach to procedural safety. A goal would be to have hospital medicine groups work collaboratively with specialists and other disciplines (eg, surgery, emergency medicine, anesthesia, or radiology) to ensure 24-hour, 7-day a week coverage of urgent bedside procedures. The potential to decrease length of stay and improve off-hour procedural quality might be a compelling rationale for hospital administration, whether or not an MPS is used. That said, we recognize that other services might be unable or unwilling to provide such coverage and that specialist off-hour coverage would incur increased costs and could reduce exposure opportunities for internal medicine residents.

A hospital-level procedures committee might be required to support an institutional imperative for procedural safety and to oversee the implementation of approaches that are practical, financially sustainable, and equitable for all service lines, especially because hospitalist groups might bear the early costs of training and retraining.

3. Hospitalist–proceduralists should collaborate with internal medicine residency programs to offer intensive procedural training experiences to residents who want these skills to be part of their future practice. Robust procedural training for trainees promotes better outcomes for the current workforce and helps to populate the future workforce with procedurally competent practitioners. Simulation-based training is a well-established procedural instruction method that is safe, authentic, and effective in terms of clinical outcomes.³⁴ As the primary teachers of residents in many institutions, hospitalists often are the ones who impart procedural skills to residents, despite uneven skill sets. It is in the interest of internal medicine residency program directors to advocate for a core group of hospitalist–proceduralists, as MPS offer an infrastructure for training that has been shown to increase procedural volume and improve skills.^47,48,50 Program directors could therefore be incentivized to sponsor some of these procedural roles with teaching and administration funds, as a trade-off for securing higher-quality procedural training and closer supervision for their trainees. The dual necessity of teaching procedural skills to residents and attending physicians alike offers economies of scale for the use of facilities, personnel, and equipment, and gives faculty an opportunity to extend their clinical teaching skills into the domain of procedural supervision.

4. Hospital medicine groups should re-evaluate credentialing and privileging to ensure procedural competency. Given the lack of published data that characterizes how many hospital medicine groups credential hospitalists to perform procedures and what practices they use to assess competency, hospital medicine groups might be signing off on procedures without verifying hospitalists’ proficiency in core procedures. SHM’s position statement on credentialing for ultrasound-guided procedures⁴⁶ describes standards that could be applied to other procedures. It proposes that credentialing processes should be grounded in simulation- and patient-based assessments of cognitive and psychomotor skills, using published checklists and global ratings for feedback. Simulation training could support provisional certification, but hospitalists should reach minimum thresholds of supervised patient-based experience before initial credentialing, with continuous reassessment of competency to mitigate skill decay. Prospectively tracking procedural metrics, such as procedural volume and complication rates, also will support systematic skill assessment. Finally, similar to any other medical error, near misses and complications should trigger periprocedural safety reviews.

Limitations

The modest body of research on hospitalists and procedures is the central limitation of our synthesis. Much of the literature consisted of consensus statements, retrospective studies, and small prospective educational studies. As a result, we did not adopt all strategies considered standard in a scoping or systematic review. The literature on MPS specifically was insufficient to draw conclusions about their operational and financial impact or effects on procedure quality. Our primary recommendation to implement MPS requires significant fiscal investment and infrastructure. It also entails risks that must be proactively addressed, including the potential for net financial loss and decreased educational opportunities for residents.

Hospitalists regularly face the predicament of being expected to independently perform procedures, with little access to training, minimal experience, and no ongoing assessment to ensure their proficiency or the safety of their patients. Past assumptions about hospitalists’ responsibility do not reflect realities in practice patterns and have not translated to widespread adoption of procedural training, monitoring, and assessment mechanisms. Our work summarizes a body of literature that, although limited in empiric studies of hospitalists themselves, offers insights with recommendations for hospital medicine groups wishing to uphold procedural skills as part of their providers’ professional identity.

Over the past 20 years, hospitalists have served as the primary workforce for the clinical care of medical inpatients in the United States.^1,2 Core competencies¹ state that hospitalists should be able to perform the following bedside procedures: lumbar puncture, paracentesis, thoracentesis, arthrocentesis, and central venous catheter placement. More recently, standard of care has dictated that these procedures be performed under ultrasound guidance,^3-6 and thus hospitalists are also expected to be adept at point-of-care ultrasound (POCUS).⁷

However, no current national standard exists for ensuring basic competency among hospitalists performing bedside procedures. In addition, hospitalists’ procedural volumes are declining,^8,9 and standards for procedural training during internal medicine residency have been reduced.¹⁰ As a result, many residents who intend to become hospitalists are no longer prepared to perform these procedures.

The ramifications of the loss of procedural competency for hospitalists are manifold. Technical errors are a significant source of patient morbidity and mortality,^11-15 and complications arising specifically from nonoperative procedures range from 0 to 19%,¹⁶ although these data do not distinguish technical errors from unpreventable adverse events nor the degree to which hospitalists contributed to these complications. Second, hospitalists in academic medical centers might be ill equipped to function as supervisors of trainees performing procedures, which could perpetuate a cycle of suboptimal technical skills.¹⁷ Finally, the discrepancy between consensus guidelines for hospitalists and their scope of practice represents a significant area of risk management for institutions that base their credentialing policies on published competencies.

There are many compelling reasons for why hospitalists should maintain—in fact reclaim—a primary role in bedside procedures.¹⁸ Hospitalists in community and rural settings might not have easy access to procedural specialists. In academic institutions, hospitalists are the primary instructors and supervisors of procedures performed by internal medicine residents. The increased availability of POCUS allows formally trained hospitalists to perform procedures more safely under imaging guidance.¹⁶

The literature on procedures performed by hospitalists, although limited, has focused on POCUS, systems innovations such as medical procedure services (MPS), and policy recommendations for procedural credentialing. Most studies on effective procedural instructional approaches have been conducted among trainees, who are procedural novices. This research does not sufficiently address the dilemma that hospitalists face as independent physicians for whom procedures are not a significant component of their practice, yet are expected to perform invasive procedures occasionally. The purpose of our literature review is to synthesize the available research to characterize contributors to hospitalists’ procedural competency. We conclude with considerations for hospital medicine practice.

We performed a structured literature search for peer-reviewed articles related to hospitalists conducting procedures, being trained in procedures, or related to hospitalist-run MPS. We focused our search on the core hospitalist procedures with the highest potential morbidity (ie, lumbar puncture, abdominal paracentesis, thoracentesis, and central venous catheterization). We searched PubMed and Google Scholar for articles published since 1996 (when the term “hospitalists” was first coined) using keyword searches for [hospitalist OR hospital medicine] AND [procedur* OR medical procedur* OR medical procedure service] OR [(procedur* AND (train* OR educat* OR teach OR instruct*)] OR abdominal paracentes* OR thoracentes* OR lumbar puncture OR central venous catheter* OR ultrasound OR point-of-care. We included original research, brief research reports, perspectives, guidelines, and consensus statements. Exclusion criteria were articles that focused on nonhospitalists and conference abstracts. We used pearling to identify secondary sources from included articles’ bibliographies, without limits on year of publication.

Trends Towards Specialist Referrals

Between 1986 and 2007, the number and variety of procedures performed by internists decreased by half.¹⁹ Hospitalists still completed procedures in greater volume and variety than nonhospitalists,⁸ with approximately 50% of hospitalists performing lumbar punctures (50%), abdominal paracenteses (49%), and thoracenteses (44%) compared with less than 25% for all three procedures for nonhospitalists. Additionally, only 11% of surveyed hospitalists⁸ performed all nine core procedures, although these included procedures that are largely cognitive in nature (eg, electrocardiogram interpretation, chest X-ray interpretation) or procedures that have been relegated to other specialists (eg, endotracheal intubation, ventilator management, or joint injection/aspiration).

Surveys showed that, especially in larger cities and academic centers, procedural specialists have taken over a disproportionate share of procedures even as the number of procedures performed continued to rise.²⁰ Between 1993 and 2008, the number of paracenteses and thoracenteses increased by 133% and decreased by 14%, respectively, but the share of procedures performed by radiologists increased by 964% and 358%, respectively, as evident in an analysis of Medicare billing data.²⁰ A more recent study of Medicare claims from 2004 to 2016 similarly revealed that the percentage of paracenteses performed by radiologists compared with nonradiologists rose from 70% to 80% and thoracenteses from 47% to 66%, respectively.²¹ Comparable trends were apparent in claims data for lumbar punctures; between 1991 and 2011, the share of lumbar punctures performed by radiologists rose from 11% to 48%.²²

In academic medical centers, hospitalists might have the opportunity to pursue other activities (eg, education, administration, research) as they progress in their careers, resulting in less clinical activity. Although hospitalists who are more clinically active in hospital care tended to perform more procedures,⁸ those with smaller clinical footprints reported lower levels of comfort with performing procedures⁸ and might have less available time to maintain procedural competency or train in new technologies such as POCUS.¹⁷

Additionally, hospitalists in both academic and community settings cited efficiency as a major reason for procedural referral. Hospitalists tended to perform more procedures if they had fixed salaries or if less than 50% of their income was based on clinical productivity, although this trend was not significant.⁸ Further, they also might be motivated by competing opportunity costs such as time lost caring for other patients or length of shift, which influences the amount of time spent at work.²³

Notably, speculation that hospitalists referred more complex cases to specialists was not borne out by studies examining referral patterns.^21,24,25

Procedural Outcomes for Hospitalists vs Nonhospitalists

No convincing data exist that procedures performed by specialists have better outcomes than those completed at the bedside by well-trained generalists, although studies were limited to the inpatient setting, to generalists who have some exposure to procedures, and to internal medicine residents on inpatient rotations. In one retrospective review, interventional radiology (IR) referrals were associated with more platelet or plasma transfusions and intensive care unit transfers than those performed at the bedside by internal medicine residents, findings that remained significant after accounting for complexity (eg, Model for End-stage Liver Disease score, need for dialysis, and platelet count).²⁴ Similarly, a prospective audit of 529 bedside procedures did not show any differences in complication rates between generalists and pulmonologists, once generalists underwent standardized training and used pleural safety checklists and ultrasound guidance.²⁶ An administrative database review of 130,000 inpatient thoracenteses across several university hospitals between 2010 and 2013 found that the risk of iatrogenic pneumothorax was similar among operators from IR, medicine, and pulmonary (2.8%, 2.9%, and 3.1%, respectively)²⁷; these findings have been reproduced in other studies.²⁸ Finally, the increasing adoption of procedural ultrasound permits procedures to be conducted more safely at the bedside, without the need to refer to radiology for imaging guidance.^3-5

IR procedures also are associated with increased healthcare costs compared with bedside procedures. One study showed that hospital costs for admissions when paracenteses were performed by radiologists were higher than those in which the procedure was completed at the bedside by gastroenterologists or hepatologists.²⁵ A chart review examining 399 paracenteses, thoracenteses, and lumbar punctures found that the average procedure cost increased by 38% for referred procedures and 56% for radiology-performed procedures, as compared with bedside procedures.²⁹ Needing ancillary staffing in dedicated suites to perform procedures contributed to the excess cost.⁹ Moreover, referred procedures resulted in increased length of stay, which can incur additional costs. However, the data were conflicting; two studies did not show a statistical difference,^25,28 while others found an increased length of stay,^24,27,29 which might be due to the unavailability of specialists during off hours, thereby delaying nonemergent procedures.²¹ Detailed cost analyses have controlled for the use of procedural facilities and blood transfusions among IR specialists and simulation training among generalists, showing that total costs were $663 per patient undergoing IR procedures compared with $134 per patient undergoing bedside procedures.³⁰

Lack of Standardized Procedural Training or Assessment

A robust body of primary studies and systematic reviews supports the use of simulation for procedural training to improve comfort and skill as well as reduce complication rates and costs.^31,32 A systematic review that investigated the impact of four paradigms of procedural training found that MPS and quality improvement/patient safety approaches led to the most active learning compared with apprenticeship (ie, “see one, do one”) and approaches based on educational theories.³³ Nevertheless, the vast majority of the research has been conducted in trainees,^32,34 with sparse evidence among practicing physicians. One cohort study of attending physicians’ central venous catheter insertion skills on simulators found low and variable short-term performance, showing overall poor adherence to checklists.³⁵ One article suggested that hospitalists’ procedural skills were below established thresholds of competency at baseline and that simulation-based training did not result in sustained skills, but the small sample size and high attrition limited meaningful conclusions.³⁶ Although continuing medical education courses are available to hospitalists, there is no published evidence supporting their effectiveness.

Proxies for procedural skill have included comfort and experience, yet these markers have broadly been shown to be inadequate.^34,36,37 Additionally, the natural decline of skill over time has invoked the need for periodic reassessment of proficiency.^36,38 Credentialing has been equally inconstant; a survey of the Society of Hospital Medicine’s (SHM) POCUS task force revealed that only half of respondents reported their hospitals required a minimum number of procedures for initial credentialing and recredentialing.³⁹ In short, periodic assessment of procedural skills among hospitalists has not been a routine process at many institutions.

Role of Hospitalist-Run Medical Procedure Services

It might not be necessary for all hospitalists to be proficient and credentialed in a given procedure,¹ and a trend has emerged in the creation of MPS staffed by hospitalists as proceduralists. The primary aim of these MPS has been to recapture the procedures—and associated revenue—that would otherwise be referred to specialists. Moreover, concentrating procedures among a core group of hospitalists endeavors to support patient safety through several principles: (1) to increase technical proficiency through higher procedural volumes, (2) to facilitate rigorous training and assessment among dedicated individuals, and (3) to systematize best practices of operator performance, communication, and documentation.

MPS have been implemented around the country and have demonstrated several advantages. In one institution, medical firms that were offered the use of an MPS had 48% more procedural attempts by nonspecialists, without significant differences in the proportions of successful attempts or complications compared with the firms who more often referred to specialists.⁴⁰ A retrospective study analyzed outcomes of 1,707 bedside procedures, of which 548 were performed by an MPS, and found that procedures done by the MPS were more likely to result in lower rates of unsuccessful procedures and to use best-practice safety processes (ie, to involve attending physicians, to use ultrasound guidance, and to avoid femoral sites for catheterization).¹² Satisfaction was high among patients who underwent bedside procedures performed by a hospitalist-supervised, intern-based procedure service with a focus on bedside communication.⁴¹ From a workforce perspective, MPS have also allowed surgical or radiological subspecialties to focus on more complex cases with higher reimbursement rates,^18,42 for proceduralists to expand beyond core procedures (eg, bone marrow biopsies⁴³), and to train advanced practice providers.⁴⁴ Although studies have not shown that the outcomes of procedures completed by an MPS are better than the outcomes of procedures performed by other specialists,⁴⁵ one can potentially extrapolate from earlier data that procedures done at the bedside by nonradiologists would have comparable outcomes.

A myriad of factors is influencing hospitalists’ scope of practice with respect to bedside procedures. Some evidence suggests that procedures performed by specialists are not superior to those done by generalists and might be associated with increased costs. The most promising developments in the past few decades include simulation-based training, which has demonstrated effectiveness across an array of clinical outcomes but has not been sufficiently evaluated in hospitalists to draw conclusions, and hospitalist-led MPS, which promote safe and productive procedural clinical practices. However, decreasing procedural volume, increasing referrals to specialists, dwindling hospitalist interest and/or confidence, time constraints, limited training opportunities, nonuniform credentialing policies, and lack of standardized assessment are cumulatively contributing to a loss of procedural competency among hospitalists.

Taken together, these forces should compel hospital medicine groups that expect their hospitalists to perform their own procedures to identify necessary steps for ensuring the safety of hospitalized patients under their care. The following considerations derive from the available—albeit modest—evidence on procedural performance in hospital medicine (Table).

1. Create MPS to establish a core set of hospitalists to perform procedures and train them using evidence-based practices. Creation of an MPS places the responsibility of core bedside procedures in the hands of a select group of proceduralists. This strategy streamlines training and assessment of individual procedural competency to meet standards set by SHM^36,46 and improves educational outcomes.^47-49 MPS could improve clinical outcomes,^12,42,50-52 including length of stay and cost, while maintaining patient satisfaction,⁴¹ as well as recoup lost revenue from referrals by increasing the volume of procedures done by generalists,^40,49 although no robust data supporting the latter point exists. Implementing an MPS requires full-time equivalent (FTE) support for proceduralists and administrative support for data collection and tracking complications. Furthermore, a well-functioning MPS will require investment in portable ultrasound machines and training in POCUS, which has been shown to decrease complications and increase success of invasive bedside procedures.^3-7 Hospital medicine groups should be aware that staffing an MPS can divert hospitalist labor and resources from other needed clinical areas, especially during the initial, low-volume phases of implementation. Strategies to offset relative value unit (RVU) loss include combining the MPS with existing clinical roles such as medical consults, code triage, and rapid response teams; or with services with lower patient caps, which might work particularly well in community hospitals. In many institutions, hospitalists can bill for procedural consults in addition to the procedures when the consult involves nonmedical patients, which is relevant when the procedure ultimately cannot be performed (eg, too little ascites to safely perform a paracentesis). Further research should establish best practices of MPS to ensure maximum procedural productivity and safety, because there are no rigorous prospective studies that evaluate strategies to create this service. Such strategies include determining the optimal ratio of proceduralists to general hospitalists, hospital characteristics that benefit most from MPS (eg, referral centers, urban-based settings), volume and type of procedures performed, and the proportion and type of referrals that are most cost-effective.

2. Establish policies with procedural specialists to arrange coverage for off-hours procedures and delineate thresholds for procedures that specialists should perform. Expanding hospitalists’ capabilities in performing procedures should trigger reconsideration of the medical center’s approach to procedural safety. A goal would be to have hospital medicine groups work collaboratively with specialists and other disciplines (eg, surgery, emergency medicine, anesthesia, or radiology) to ensure 24-hour, 7-day a week coverage of urgent bedside procedures. The potential to decrease length of stay and improve off-hour procedural quality might be a compelling rationale for hospital administration, whether or not an MPS is used. That said, we recognize that other services might be unable or unwilling to provide such coverage and that specialist off-hour coverage would incur increased costs and could reduce exposure opportunities for internal medicine residents.

A hospital-level procedures committee might be required to support an institutional imperative for procedural safety and to oversee the implementation of approaches that are practical, financially sustainable, and equitable for all service lines, especially because hospitalist groups might bear the early costs of training and retraining.

3. Hospitalist–proceduralists should collaborate with internal medicine residency programs to offer intensive procedural training experiences to residents who want these skills to be part of their future practice. Robust procedural training for trainees promotes better outcomes for the current workforce and helps to populate the future workforce with procedurally competent practitioners. Simulation-based training is a well-established procedural instruction method that is safe, authentic, and effective in terms of clinical outcomes.³⁴ As the primary teachers of residents in many institutions, hospitalists often are the ones who impart procedural skills to residents, despite uneven skill sets. It is in the interest of internal medicine residency program directors to advocate for a core group of hospitalist–proceduralists, as MPS offer an infrastructure for training that has been shown to increase procedural volume and improve skills.^47,48,50 Program directors could therefore be incentivized to sponsor some of these procedural roles with teaching and administration funds, as a trade-off for securing higher-quality procedural training and closer supervision for their trainees. The dual necessity of teaching procedural skills to residents and attending physicians alike offers economies of scale for the use of facilities, personnel, and equipment, and gives faculty an opportunity to extend their clinical teaching skills into the domain of procedural supervision.

4. Hospital medicine groups should re-evaluate credentialing and privileging to ensure procedural competency. Given the lack of published data that characterizes how many hospital medicine groups credential hospitalists to perform procedures and what practices they use to assess competency, hospital medicine groups might be signing off on procedures without verifying hospitalists’ proficiency in core procedures. SHM’s position statement on credentialing for ultrasound-guided procedures⁴⁶ describes standards that could be applied to other procedures. It proposes that credentialing processes should be grounded in simulation- and patient-based assessments of cognitive and psychomotor skills, using published checklists and global ratings for feedback. Simulation training could support provisional certification, but hospitalists should reach minimum thresholds of supervised patient-based experience before initial credentialing, with continuous reassessment of competency to mitigate skill decay. Prospectively tracking procedural metrics, such as procedural volume and complication rates, also will support systematic skill assessment. Finally, similar to any other medical error, near misses and complications should trigger periprocedural safety reviews.

Limitations

The modest body of research on hospitalists and procedures is the central limitation of our synthesis. Much of the literature consisted of consensus statements, retrospective studies, and small prospective educational studies. As a result, we did not adopt all strategies considered standard in a scoping or systematic review. The literature on MPS specifically was insufficient to draw conclusions about their operational and financial impact or effects on procedure quality. Our primary recommendation to implement MPS requires significant fiscal investment and infrastructure. It also entails risks that must be proactively addressed, including the potential for net financial loss and decreased educational opportunities for residents.

Hospitalists regularly face the predicament of being expected to independently perform procedures, with little access to training, minimal experience, and no ongoing assessment to ensure their proficiency or the safety of their patients. Past assumptions about hospitalists’ responsibility do not reflect realities in practice patterns and have not translated to widespread adoption of procedural training, monitoring, and assessment mechanisms. Our work summarizes a body of literature that, although limited in empiric studies of hospitalists themselves, offers insights with recommendations for hospital medicine groups wishing to uphold procedural skills as part of their providers’ professional identity.

Over the past 20 years, hospitalists have served as the primary workforce for the clinical care of medical inpatients in the United States.^1,2 Core competencies¹ state that hospitalists should be able to perform the following bedside procedures: lumbar puncture, paracentesis, thoracentesis, arthrocentesis, and central venous catheter placement. More recently, standard of care has dictated that these procedures be performed under ultrasound guidance,^3-6 and thus hospitalists are also expected to be adept at point-of-care ultrasound (POCUS).⁷

However, no current national standard exists for ensuring basic competency among hospitalists performing bedside procedures. In addition, hospitalists’ procedural volumes are declining,^8,9 and standards for procedural training during internal medicine residency have been reduced.¹⁰ As a result, many residents who intend to become hospitalists are no longer prepared to perform these procedures.

The ramifications of the loss of procedural competency for hospitalists are manifold. Technical errors are a significant source of patient morbidity and mortality,^11-15 and complications arising specifically from nonoperative procedures range from 0 to 19%,¹⁶ although these data do not distinguish technical errors from unpreventable adverse events nor the degree to which hospitalists contributed to these complications. Second, hospitalists in academic medical centers might be ill equipped to function as supervisors of trainees performing procedures, which could perpetuate a cycle of suboptimal technical skills.¹⁷ Finally, the discrepancy between consensus guidelines for hospitalists and their scope of practice represents a significant area of risk management for institutions that base their credentialing policies on published competencies.

There are many compelling reasons for why hospitalists should maintain—in fact reclaim—a primary role in bedside procedures.¹⁸ Hospitalists in community and rural settings might not have easy access to procedural specialists. In academic institutions, hospitalists are the primary instructors and supervisors of procedures performed by internal medicine residents. The increased availability of POCUS allows formally trained hospitalists to perform procedures more safely under imaging guidance.¹⁶

The literature on procedures performed by hospitalists, although limited, has focused on POCUS, systems innovations such as medical procedure services (MPS), and policy recommendations for procedural credentialing. Most studies on effective procedural instructional approaches have been conducted among trainees, who are procedural novices. This research does not sufficiently address the dilemma that hospitalists face as independent physicians for whom procedures are not a significant component of their practice, yet are expected to perform invasive procedures occasionally. The purpose of our literature review is to synthesize the available research to characterize contributors to hospitalists’ procedural competency. We conclude with considerations for hospital medicine practice.

We performed a structured literature search for peer-reviewed articles related to hospitalists conducting procedures, being trained in procedures, or related to hospitalist-run MPS. We focused our search on the core hospitalist procedures with the highest potential morbidity (ie, lumbar puncture, abdominal paracentesis, thoracentesis, and central venous catheterization). We searched PubMed and Google Scholar for articles published since 1996 (when the term “hospitalists” was first coined) using keyword searches for [hospitalist OR hospital medicine] AND [procedur* OR medical procedur* OR medical procedure service] OR [(procedur* AND (train* OR educat* OR teach OR instruct*)] OR abdominal paracentes* OR thoracentes* OR lumbar puncture OR central venous catheter* OR ultrasound OR point-of-care. We included original research, brief research reports, perspectives, guidelines, and consensus statements. Exclusion criteria were articles that focused on nonhospitalists and conference abstracts. We used pearling to identify secondary sources from included articles’ bibliographies, without limits on year of publication.

Trends Towards Specialist Referrals

Between 1986 and 2007, the number and variety of procedures performed by internists decreased by half.¹⁹ Hospitalists still completed procedures in greater volume and variety than nonhospitalists,⁸ with approximately 50% of hospitalists performing lumbar punctures (50%), abdominal paracenteses (49%), and thoracenteses (44%) compared with less than 25% for all three procedures for nonhospitalists. Additionally, only 11% of surveyed hospitalists⁸ performed all nine core procedures, although these included procedures that are largely cognitive in nature (eg, electrocardiogram interpretation, chest X-ray interpretation) or procedures that have been relegated to other specialists (eg, endotracheal intubation, ventilator management, or joint injection/aspiration).

Surveys showed that, especially in larger cities and academic centers, procedural specialists have taken over a disproportionate share of procedures even as the number of procedures performed continued to rise.²⁰ Between 1993 and 2008, the number of paracenteses and thoracenteses increased by 133% and decreased by 14%, respectively, but the share of procedures performed by radiologists increased by 964% and 358%, respectively, as evident in an analysis of Medicare billing data.²⁰ A more recent study of Medicare claims from 2004 to 2016 similarly revealed that the percentage of paracenteses performed by radiologists compared with nonradiologists rose from 70% to 80% and thoracenteses from 47% to 66%, respectively.²¹ Comparable trends were apparent in claims data for lumbar punctures; between 1991 and 2011, the share of lumbar punctures performed by radiologists rose from 11% to 48%.²²

In academic medical centers, hospitalists might have the opportunity to pursue other activities (eg, education, administration, research) as they progress in their careers, resulting in less clinical activity. Although hospitalists who are more clinically active in hospital care tended to perform more procedures,⁸ those with smaller clinical footprints reported lower levels of comfort with performing procedures⁸ and might have less available time to maintain procedural competency or train in new technologies such as POCUS.¹⁷

Additionally, hospitalists in both academic and community settings cited efficiency as a major reason for procedural referral. Hospitalists tended to perform more procedures if they had fixed salaries or if less than 50% of their income was based on clinical productivity, although this trend was not significant.⁸ Further, they also might be motivated by competing opportunity costs such as time lost caring for other patients or length of shift, which influences the amount of time spent at work.²³

Notably, speculation that hospitalists referred more complex cases to specialists was not borne out by studies examining referral patterns.^21,24,25

Procedural Outcomes for Hospitalists vs Nonhospitalists

No convincing data exist that procedures performed by specialists have better outcomes than those completed at the bedside by well-trained generalists, although studies were limited to the inpatient setting, to generalists who have some exposure to procedures, and to internal medicine residents on inpatient rotations. In one retrospective review, interventional radiology (IR) referrals were associated with more platelet or plasma transfusions and intensive care unit transfers than those performed at the bedside by internal medicine residents, findings that remained significant after accounting for complexity (eg, Model for End-stage Liver Disease score, need for dialysis, and platelet count).²⁴ Similarly, a prospective audit of 529 bedside procedures did not show any differences in complication rates between generalists and pulmonologists, once generalists underwent standardized training and used pleural safety checklists and ultrasound guidance.²⁶ An administrative database review of 130,000 inpatient thoracenteses across several university hospitals between 2010 and 2013 found that the risk of iatrogenic pneumothorax was similar among operators from IR, medicine, and pulmonary (2.8%, 2.9%, and 3.1%, respectively)²⁷; these findings have been reproduced in other studies.²⁸ Finally, the increasing adoption of procedural ultrasound permits procedures to be conducted more safely at the bedside, without the need to refer to radiology for imaging guidance.^3-5

IR procedures also are associated with increased healthcare costs compared with bedside procedures. One study showed that hospital costs for admissions when paracenteses were performed by radiologists were higher than those in which the procedure was completed at the bedside by gastroenterologists or hepatologists.²⁵ A chart review examining 399 paracenteses, thoracenteses, and lumbar punctures found that the average procedure cost increased by 38% for referred procedures and 56% for radiology-performed procedures, as compared with bedside procedures.²⁹ Needing ancillary staffing in dedicated suites to perform procedures contributed to the excess cost.⁹ Moreover, referred procedures resulted in increased length of stay, which can incur additional costs. However, the data were conflicting; two studies did not show a statistical difference,^25,28 while others found an increased length of stay,^24,27,29 which might be due to the unavailability of specialists during off hours, thereby delaying nonemergent procedures.²¹ Detailed cost analyses have controlled for the use of procedural facilities and blood transfusions among IR specialists and simulation training among generalists, showing that total costs were $663 per patient undergoing IR procedures compared with $134 per patient undergoing bedside procedures.³⁰

Lack of Standardized Procedural Training or Assessment

A robust body of primary studies and systematic reviews supports the use of simulation for procedural training to improve comfort and skill as well as reduce complication rates and costs.^31,32 A systematic review that investigated the impact of four paradigms of procedural training found that MPS and quality improvement/patient safety approaches led to the most active learning compared with apprenticeship (ie, “see one, do one”) and approaches based on educational theories.³³ Nevertheless, the vast majority of the research has been conducted in trainees,^32,34 with sparse evidence among practicing physicians. One cohort study of attending physicians’ central venous catheter insertion skills on simulators found low and variable short-term performance, showing overall poor adherence to checklists.³⁵ One article suggested that hospitalists’ procedural skills were below established thresholds of competency at baseline and that simulation-based training did not result in sustained skills, but the small sample size and high attrition limited meaningful conclusions.³⁶ Although continuing medical education courses are available to hospitalists, there is no published evidence supporting their effectiveness.

Proxies for procedural skill have included comfort and experience, yet these markers have broadly been shown to be inadequate.^34,36,37 Additionally, the natural decline of skill over time has invoked the need for periodic reassessment of proficiency.^36,38 Credentialing has been equally inconstant; a survey of the Society of Hospital Medicine’s (SHM) POCUS task force revealed that only half of respondents reported their hospitals required a minimum number of procedures for initial credentialing and recredentialing.³⁹ In short, periodic assessment of procedural skills among hospitalists has not been a routine process at many institutions.

Role of Hospitalist-Run Medical Procedure Services

It might not be necessary for all hospitalists to be proficient and credentialed in a given procedure,¹ and a trend has emerged in the creation of MPS staffed by hospitalists as proceduralists. The primary aim of these MPS has been to recapture the procedures—and associated revenue—that would otherwise be referred to specialists. Moreover, concentrating procedures among a core group of hospitalists endeavors to support patient safety through several principles: (1) to increase technical proficiency through higher procedural volumes, (2) to facilitate rigorous training and assessment among dedicated individuals, and (3) to systematize best practices of operator performance, communication, and documentation.

MPS have been implemented around the country and have demonstrated several advantages. In one institution, medical firms that were offered the use of an MPS had 48% more procedural attempts by nonspecialists, without significant differences in the proportions of successful attempts or complications compared with the firms who more often referred to specialists.⁴⁰ A retrospective study analyzed outcomes of 1,707 bedside procedures, of which 548 were performed by an MPS, and found that procedures done by the MPS were more likely to result in lower rates of unsuccessful procedures and to use best-practice safety processes (ie, to involve attending physicians, to use ultrasound guidance, and to avoid femoral sites for catheterization).¹² Satisfaction was high among patients who underwent bedside procedures performed by a hospitalist-supervised, intern-based procedure service with a focus on bedside communication.⁴¹ From a workforce perspective, MPS have also allowed surgical or radiological subspecialties to focus on more complex cases with higher reimbursement rates,^18,42 for proceduralists to expand beyond core procedures (eg, bone marrow biopsies⁴³), and to train advanced practice providers.⁴⁴ Although studies have not shown that the outcomes of procedures completed by an MPS are better than the outcomes of procedures performed by other specialists,⁴⁵ one can potentially extrapolate from earlier data that procedures done at the bedside by nonradiologists would have comparable outcomes.

A myriad of factors is influencing hospitalists’ scope of practice with respect to bedside procedures. Some evidence suggests that procedures performed by specialists are not superior to those done by generalists and might be associated with increased costs. The most promising developments in the past few decades include simulation-based training, which has demonstrated effectiveness across an array of clinical outcomes but has not been sufficiently evaluated in hospitalists to draw conclusions, and hospitalist-led MPS, which promote safe and productive procedural clinical practices. However, decreasing procedural volume, increasing referrals to specialists, dwindling hospitalist interest and/or confidence, time constraints, limited training opportunities, nonuniform credentialing policies, and lack of standardized assessment are cumulatively contributing to a loss of procedural competency among hospitalists.

Taken together, these forces should compel hospital medicine groups that expect their hospitalists to perform their own procedures to identify necessary steps for ensuring the safety of hospitalized patients under their care. The following considerations derive from the available—albeit modest—evidence on procedural performance in hospital medicine (Table).

1. Create MPS to establish a core set of hospitalists to perform procedures and train them using evidence-based practices. Creation of an MPS places the responsibility of core bedside procedures in the hands of a select group of proceduralists. This strategy streamlines training and assessment of individual procedural competency to meet standards set by SHM^36,46 and improves educational outcomes.^47-49 MPS could improve clinical outcomes,^12,42,50-52 including length of stay and cost, while maintaining patient satisfaction,⁴¹ as well as recoup lost revenue from referrals by increasing the volume of procedures done by generalists,^40,49 although no robust data supporting the latter point exists. Implementing an MPS requires full-time equivalent (FTE) support for proceduralists and administrative support for data collection and tracking complications. Furthermore, a well-functioning MPS will require investment in portable ultrasound machines and training in POCUS, which has been shown to decrease complications and increase success of invasive bedside procedures.^3-7 Hospital medicine groups should be aware that staffing an MPS can divert hospitalist labor and resources from other needed clinical areas, especially during the initial, low-volume phases of implementation. Strategies to offset relative value unit (RVU) loss include combining the MPS with existing clinical roles such as medical consults, code triage, and rapid response teams; or with services with lower patient caps, which might work particularly well in community hospitals. In many institutions, hospitalists can bill for procedural consults in addition to the procedures when the consult involves nonmedical patients, which is relevant when the procedure ultimately cannot be performed (eg, too little ascites to safely perform a paracentesis). Further research should establish best practices of MPS to ensure maximum procedural productivity and safety, because there are no rigorous prospective studies that evaluate strategies to create this service. Such strategies include determining the optimal ratio of proceduralists to general hospitalists, hospital characteristics that benefit most from MPS (eg, referral centers, urban-based settings), volume and type of procedures performed, and the proportion and type of referrals that are most cost-effective.

2. Establish policies with procedural specialists to arrange coverage for off-hours procedures and delineate thresholds for procedures that specialists should perform. Expanding hospitalists’ capabilities in performing procedures should trigger reconsideration of the medical center’s approach to procedural safety. A goal would be to have hospital medicine groups work collaboratively with specialists and other disciplines (eg, surgery, emergency medicine, anesthesia, or radiology) to ensure 24-hour, 7-day a week coverage of urgent bedside procedures. The potential to decrease length of stay and improve off-hour procedural quality might be a compelling rationale for hospital administration, whether or not an MPS is used. That said, we recognize that other services might be unable or unwilling to provide such coverage and that specialist off-hour coverage would incur increased costs and could reduce exposure opportunities for internal medicine residents.

A hospital-level procedures committee might be required to support an institutional imperative for procedural safety and to oversee the implementation of approaches that are practical, financially sustainable, and equitable for all service lines, especially because hospitalist groups might bear the early costs of training and retraining.

3. Hospitalist–proceduralists should collaborate with internal medicine residency programs to offer intensive procedural training experiences to residents who want these skills to be part of their future practice. Robust procedural training for trainees promotes better outcomes for the current workforce and helps to populate the future workforce with procedurally competent practitioners. Simulation-based training is a well-established procedural instruction method that is safe, authentic, and effective in terms of clinical outcomes.³⁴ As the primary teachers of residents in many institutions, hospitalists often are the ones who impart procedural skills to residents, despite uneven skill sets. It is in the interest of internal medicine residency program directors to advocate for a core group of hospitalist–proceduralists, as MPS offer an infrastructure for training that has been shown to increase procedural volume and improve skills.^47,48,50 Program directors could therefore be incentivized to sponsor some of these procedural roles with teaching and administration funds, as a trade-off for securing higher-quality procedural training and closer supervision for their trainees. The dual necessity of teaching procedural skills to residents and attending physicians alike offers economies of scale for the use of facilities, personnel, and equipment, and gives faculty an opportunity to extend their clinical teaching skills into the domain of procedural supervision.

4. Hospital medicine groups should re-evaluate credentialing and privileging to ensure procedural competency. Given the lack of published data that characterizes how many hospital medicine groups credential hospitalists to perform procedures and what practices they use to assess competency, hospital medicine groups might be signing off on procedures without verifying hospitalists’ proficiency in core procedures. SHM’s position statement on credentialing for ultrasound-guided procedures⁴⁶ describes standards that could be applied to other procedures. It proposes that credentialing processes should be grounded in simulation- and patient-based assessments of cognitive and psychomotor skills, using published checklists and global ratings for feedback. Simulation training could support provisional certification, but hospitalists should reach minimum thresholds of supervised patient-based experience before initial credentialing, with continuous reassessment of competency to mitigate skill decay. Prospectively tracking procedural metrics, such as procedural volume and complication rates, also will support systematic skill assessment. Finally, similar to any other medical error, near misses and complications should trigger periprocedural safety reviews.

Limitations

The modest body of research on hospitalists and procedures is the central limitation of our synthesis. Much of the literature consisted of consensus statements, retrospective studies, and small prospective educational studies. As a result, we did not adopt all strategies considered standard in a scoping or systematic review. The literature on MPS specifically was insufficient to draw conclusions about their operational and financial impact or effects on procedure quality. Our primary recommendation to implement MPS requires significant fiscal investment and infrastructure. It also entails risks that must be proactively addressed, including the potential for net financial loss and decreased educational opportunities for residents.

Hospitalists regularly face the predicament of being expected to independently perform procedures, with little access to training, minimal experience, and no ongoing assessment to ensure their proficiency or the safety of their patients. Past assumptions about hospitalists’ responsibility do not reflect realities in practice patterns and have not translated to widespread adoption of procedural training, monitoring, and assessment mechanisms. Our work summarizes a body of literature that, although limited in empiric studies of hospitalists themselves, offers insights with recommendations for hospital medicine groups wishing to uphold procedural skills as part of their providers’ professional identity.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

A 54-year-old immunocompetent man admitted to the hospital for non–ST-segment elevation myocardial infarction develops profuse watery diarrhea after his third day of admission. He denies prior episodes of diarrhea. He does not have any fevers, blood in the stool, recent travel, or antibiotic use. Vital signs include a blood pressure of 128/82 mm Hg, heart rate of 120 beats per minute, respiratory rate of 16 breaths per min, oxygen saturation of 100% on room air, and temperature of 36.9 °C. His physical examination is normal, without signs of abdominal tenderness, rebound, or guarding. Complete blood count is normal, without eosinophilia. The comprehensive metabolic panel shows mild hypokalemia of 3.3 mmol/L. The hospitalist resuscitates him with normal saline, provides oral potassium repletion, and orders a stool culture, Clostridioides difficile test, and an ova and parasite (O&P) test. Loperamide and time resolve his symptoms in 2 days. Results of his stool culture, C difficile, and O&P tests return negative in 3 days.

Acute diarrhea is a common complaint in both inpatient and outpatient settings. It is defined as the passage of three or more liquid or poorly formed stools in a 24-hour period lasting less than 14 days. Persistent diarrhea lasts from 14 to 29 days, while chronic diarrhea lasts longer than 30 days. There are 47.8 million cases of acute diarrhea per year in the United States, costing $150 million in US health expenditures.¹ Viral pathogens remain the most common cause of acute diarrhea in the United States.^1,2 Standard O&P testing consists of applying a stool sample to a slide with either saline or iodine (wet mount) and evaluating the specimen with a microscope.

Giardia and Cryptosporidium remain the most commonly implicated parasitic pathogens in acute diarrheal episodes in the United States.³Cryptosporidium cases in the United States range from 2.2 to 3.9 per 100,000 persons,⁴ and Giardia cases in the United States range from 5.8 to 6.4 per 100,000 persons.⁵ To avoid missing potentially treatable causes, providers often order O&P tests reflexively as part of a standard workup for acute diarrhea. From 2001 to 2007, Associated Regional and University Pathologists Laboratories experienced a 379% increase in O&P testing.⁶ Many providers ordering these tests assume that standard O&P testing covers most, if not all, parasites and that a negative test will rule out a parasitic cause of disease. Furthermore, providers are unaware that more sensitive tests to detect certain parasites have replaced standard O&P microscopy.³

Most hospitalized patients do not have a parasitic infection

In a review of 5,681 completed O&P tests from a tertiary care medical center in Canada over a 5-year period, only 1.4% of tests were positive.⁷ In a 3-year retrospective analysis of stool samples obtained after 3 days of hospitalization, positive results were found in only 1 of 191 stool cultures and in 0 of 90 O&P samples.⁸ Current practice guidelines suggest not testing patients with stool studies in cases of acute diarrhea lasting less than 7 days in the absence of significant risk factors for parasitic disease because it has been shown to be a rare event and most cases will self-resolve with supportive care only.^1,9

The stool O&P test has low sensitivity

Classically ordered stool O&P tests have low sensitivity for the detection of Giardia and Cryptosporidium, the two most common parasites in the United States.^6,10,11 O&P studies detect Giardia in only 66% to 79% of specimen samples and Cryptosporidium in less than 5% of specimens. Diagnostic yields can be improved with the use of special stains such as modified acid-fast stain (MAF).⁶ Despite use of MAF staining, though, sensitivity for Cryptosporidium detection has remained at only 55%.¹² Additionally, several studies have shown that physicians are generally unaware of the test characteristics of stool O&P tests and they do not know to order the newer more sensitive enzyme immunoassays (EIA) or direct fluorescent antibody (DFA) tests even in situations when testing for a parasitic infection is appropriate.^10,11,13,14 As stated earlier, a parasitic infection without significant risk factors is a rare event. A negative test with low or moderate sensitivity is not additive to such a low clinical suspicion because it does not significantly change posttest probability.

Testing can have adverse consequences

In addition to the low yield, O&P testing is technically complex, is time intensive, and requires an experienced technician’s interpretation. Inappropriate testing increases the cost of care and staff workload without much benefit.⁶ As such, some institutions have opted to send the O&P tests to labs with experienced technicians. Other institutions have adopted a restrictive stool O&P testing approach that reduces healthcare time and costs and improves the rate of positive tests.^13,15 A study at a single tertiary care medical center demonstrated an estimated cost savings of $21,931 annually by implementing a computer-based algorithm to restrict testing for stool cultures and O&P tests to patients with higher probabilities of infection.¹⁵ The algorithm directed clinicians to provide further information when attempting to order stool culture, O&P, or other specific stool tests. For patients hospitalized for more than 3 days, the system did not allow certain testing. For patients with worrisome features like severe symptoms or an immunocompromised state, the algorithm directed the clinician to place an infectious disease or gastroenterology consult rather than order stool tests. Decreased laboratory costs of all stool studies (including O&P) in adult inpatient locations led to the cost savings. Additionally, the study authors felt that they likely underestimated the cost savings because they did not account for other expenses in the analysis, such as nursing workload and supplies.¹⁵

Clinicians should evaluate patients on a case-by-case basis and determine the need to test based on the presence of high-risk features (Table).

When performing parasitic testing in patients without a recent travel history but with other high-risk features, test for the most prevalent parasites in the United States (ie, Giardia, Cryptosporidium, and Entamoeba histolytica) with DFA or EIA tests.³ DFA testing for Giardia is 99% sensitive.¹² In patients with symptoms lasting more than 7 days and recent travel, in addition to the above DFA/EIA tests, perform O&P testing with wet mount, modified acid-fast bacilli stain to detect rare parasites such as helminths, Strongyloides, Cyclospora, and Cystoisospora.³ In patients who live or travel to endemic areas (about 10% of traveler’s diarrhea is caused by parasitic infections), have unexplained eosinophilia, or are part of a community outbreak (eg, childcare institutions or drinking water/food outbreaks), test for Giardia, Cryptosporidium, Cyclospora, Cystoisospora, Entamoeba histolytica, and Isospora belli.⁹ In addition, among patients with AIDS or immunosuppression, testing should include assays for Microsporidia, Strongyloides, and Mycobacterium avium complex (Figure).^9,16 Newer tests, such as the multiplex real-time polymerase chain reaction assay, can also simultaneously detect Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum. For more information on parasitic testing, we suggest reading the review article “Beyond O&P times three.”³ It is important to familiarize yourself with the parasitic tests available at your respective clinics/hospital so the optimal test can be used.

• Prescribe a trial of “wait and see” for patients without high-risk features for parasitic disease.
• Test patients with high-risk features for parasitic disease by utilizing targeted testing.
• For patients with high-risk features but no travel history, first perform DFA, EIA, or multiplex real-time polymerase chain reaction testing to evaluate for Giardia, Cryptosporidium, and Entamoeba histolytica.
• If DFA/EIA testing is negative, obtain O&P tests with and without stains, such as acid-fast bacilli, for detection of other rare parasites.

Hospitalists should risk-stratify patients to determine when O&P testing is appropriate. Employ more targeted testing, especially use of DFA/EIA tests when evaluating for parasites. Avoid parasitic testing if symptoms have lasted less than 7 days and the patient has no other high-risk features. Become familiar with the tests available at your institution and their sensitivities. As in our clinical scenario, most acute cases of diarrhea resolve without intervention and should be managed and treated conservatively.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason ^™ ” topics by emailing [email protected] .

The authors thank Dr Lenny Feldman for his assistance with editing the manuscript.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

A 54-year-old immunocompetent man admitted to the hospital for non–ST-segment elevation myocardial infarction develops profuse watery diarrhea after his third day of admission. He denies prior episodes of diarrhea. He does not have any fevers, blood in the stool, recent travel, or antibiotic use. Vital signs include a blood pressure of 128/82 mm Hg, heart rate of 120 beats per minute, respiratory rate of 16 breaths per min, oxygen saturation of 100% on room air, and temperature of 36.9 °C. His physical examination is normal, without signs of abdominal tenderness, rebound, or guarding. Complete blood count is normal, without eosinophilia. The comprehensive metabolic panel shows mild hypokalemia of 3.3 mmol/L. The hospitalist resuscitates him with normal saline, provides oral potassium repletion, and orders a stool culture, Clostridioides difficile test, and an ova and parasite (O&P) test. Loperamide and time resolve his symptoms in 2 days. Results of his stool culture, C difficile, and O&P tests return negative in 3 days.

Acute diarrhea is a common complaint in both inpatient and outpatient settings. It is defined as the passage of three or more liquid or poorly formed stools in a 24-hour period lasting less than 14 days. Persistent diarrhea lasts from 14 to 29 days, while chronic diarrhea lasts longer than 30 days. There are 47.8 million cases of acute diarrhea per year in the United States, costing $150 million in US health expenditures.¹ Viral pathogens remain the most common cause of acute diarrhea in the United States.^1,2 Standard O&P testing consists of applying a stool sample to a slide with either saline or iodine (wet mount) and evaluating the specimen with a microscope.

Giardia and Cryptosporidium remain the most commonly implicated parasitic pathogens in acute diarrheal episodes in the United States.³Cryptosporidium cases in the United States range from 2.2 to 3.9 per 100,000 persons,⁴ and Giardia cases in the United States range from 5.8 to 6.4 per 100,000 persons.⁵ To avoid missing potentially treatable causes, providers often order O&P tests reflexively as part of a standard workup for acute diarrhea. From 2001 to 2007, Associated Regional and University Pathologists Laboratories experienced a 379% increase in O&P testing.⁶ Many providers ordering these tests assume that standard O&P testing covers most, if not all, parasites and that a negative test will rule out a parasitic cause of disease. Furthermore, providers are unaware that more sensitive tests to detect certain parasites have replaced standard O&P microscopy.³

Most hospitalized patients do not have a parasitic infection

In a review of 5,681 completed O&P tests from a tertiary care medical center in Canada over a 5-year period, only 1.4% of tests were positive.⁷ In a 3-year retrospective analysis of stool samples obtained after 3 days of hospitalization, positive results were found in only 1 of 191 stool cultures and in 0 of 90 O&P samples.⁸ Current practice guidelines suggest not testing patients with stool studies in cases of acute diarrhea lasting less than 7 days in the absence of significant risk factors for parasitic disease because it has been shown to be a rare event and most cases will self-resolve with supportive care only.^1,9

The stool O&P test has low sensitivity

Classically ordered stool O&P tests have low sensitivity for the detection of Giardia and Cryptosporidium, the two most common parasites in the United States.^6,10,11 O&P studies detect Giardia in only 66% to 79% of specimen samples and Cryptosporidium in less than 5% of specimens. Diagnostic yields can be improved with the use of special stains such as modified acid-fast stain (MAF).⁶ Despite use of MAF staining, though, sensitivity for Cryptosporidium detection has remained at only 55%.¹² Additionally, several studies have shown that physicians are generally unaware of the test characteristics of stool O&P tests and they do not know to order the newer more sensitive enzyme immunoassays (EIA) or direct fluorescent antibody (DFA) tests even in situations when testing for a parasitic infection is appropriate.^10,11,13,14 As stated earlier, a parasitic infection without significant risk factors is a rare event. A negative test with low or moderate sensitivity is not additive to such a low clinical suspicion because it does not significantly change posttest probability.

Testing can have adverse consequences

In addition to the low yield, O&P testing is technically complex, is time intensive, and requires an experienced technician’s interpretation. Inappropriate testing increases the cost of care and staff workload without much benefit.⁶ As such, some institutions have opted to send the O&P tests to labs with experienced technicians. Other institutions have adopted a restrictive stool O&P testing approach that reduces healthcare time and costs and improves the rate of positive tests.^13,15 A study at a single tertiary care medical center demonstrated an estimated cost savings of $21,931 annually by implementing a computer-based algorithm to restrict testing for stool cultures and O&P tests to patients with higher probabilities of infection.¹⁵ The algorithm directed clinicians to provide further information when attempting to order stool culture, O&P, or other specific stool tests. For patients hospitalized for more than 3 days, the system did not allow certain testing. For patients with worrisome features like severe symptoms or an immunocompromised state, the algorithm directed the clinician to place an infectious disease or gastroenterology consult rather than order stool tests. Decreased laboratory costs of all stool studies (including O&P) in adult inpatient locations led to the cost savings. Additionally, the study authors felt that they likely underestimated the cost savings because they did not account for other expenses in the analysis, such as nursing workload and supplies.¹⁵

Clinicians should evaluate patients on a case-by-case basis and determine the need to test based on the presence of high-risk features (Table).

When performing parasitic testing in patients without a recent travel history but with other high-risk features, test for the most prevalent parasites in the United States (ie, Giardia, Cryptosporidium, and Entamoeba histolytica) with DFA or EIA tests.³ DFA testing for Giardia is 99% sensitive.¹² In patients with symptoms lasting more than 7 days and recent travel, in addition to the above DFA/EIA tests, perform O&P testing with wet mount, modified acid-fast bacilli stain to detect rare parasites such as helminths, Strongyloides, Cyclospora, and Cystoisospora.³ In patients who live or travel to endemic areas (about 10% of traveler’s diarrhea is caused by parasitic infections), have unexplained eosinophilia, or are part of a community outbreak (eg, childcare institutions or drinking water/food outbreaks), test for Giardia, Cryptosporidium, Cyclospora, Cystoisospora, Entamoeba histolytica, and Isospora belli.⁹ In addition, among patients with AIDS or immunosuppression, testing should include assays for Microsporidia, Strongyloides, and Mycobacterium avium complex (Figure).^9,16 Newer tests, such as the multiplex real-time polymerase chain reaction assay, can also simultaneously detect Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum. For more information on parasitic testing, we suggest reading the review article “Beyond O&P times three.”³ It is important to familiarize yourself with the parasitic tests available at your respective clinics/hospital so the optimal test can be used.

• Prescribe a trial of “wait and see” for patients without high-risk features for parasitic disease.
• Test patients with high-risk features for parasitic disease by utilizing targeted testing.
• For patients with high-risk features but no travel history, first perform DFA, EIA, or multiplex real-time polymerase chain reaction testing to evaluate for Giardia, Cryptosporidium, and Entamoeba histolytica.
• If DFA/EIA testing is negative, obtain O&P tests with and without stains, such as acid-fast bacilli, for detection of other rare parasites.

Hospitalists should risk-stratify patients to determine when O&P testing is appropriate. Employ more targeted testing, especially use of DFA/EIA tests when evaluating for parasites. Avoid parasitic testing if symptoms have lasted less than 7 days and the patient has no other high-risk features. Become familiar with the tests available at your institution and their sensitivities. As in our clinical scenario, most acute cases of diarrhea resolve without intervention and should be managed and treated conservatively.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason ^™ ” topics by emailing [email protected] .

The authors thank Dr Lenny Feldman for his assistance with editing the manuscript.

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent clear-cut conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

A 54-year-old immunocompetent man admitted to the hospital for non–ST-segment elevation myocardial infarction develops profuse watery diarrhea after his third day of admission. He denies prior episodes of diarrhea. He does not have any fevers, blood in the stool, recent travel, or antibiotic use. Vital signs include a blood pressure of 128/82 mm Hg, heart rate of 120 beats per minute, respiratory rate of 16 breaths per min, oxygen saturation of 100% on room air, and temperature of 36.9 °C. His physical examination is normal, without signs of abdominal tenderness, rebound, or guarding. Complete blood count is normal, without eosinophilia. The comprehensive metabolic panel shows mild hypokalemia of 3.3 mmol/L. The hospitalist resuscitates him with normal saline, provides oral potassium repletion, and orders a stool culture, Clostridioides difficile test, and an ova and parasite (O&P) test. Loperamide and time resolve his symptoms in 2 days. Results of his stool culture, C difficile, and O&P tests return negative in 3 days.

Acute diarrhea is a common complaint in both inpatient and outpatient settings. It is defined as the passage of three or more liquid or poorly formed stools in a 24-hour period lasting less than 14 days. Persistent diarrhea lasts from 14 to 29 days, while chronic diarrhea lasts longer than 30 days. There are 47.8 million cases of acute diarrhea per year in the United States, costing $150 million in US health expenditures.¹ Viral pathogens remain the most common cause of acute diarrhea in the United States.^1,2 Standard O&P testing consists of applying a stool sample to a slide with either saline or iodine (wet mount) and evaluating the specimen with a microscope.

Giardia and Cryptosporidium remain the most commonly implicated parasitic pathogens in acute diarrheal episodes in the United States.³Cryptosporidium cases in the United States range from 2.2 to 3.9 per 100,000 persons,⁴ and Giardia cases in the United States range from 5.8 to 6.4 per 100,000 persons.⁵ To avoid missing potentially treatable causes, providers often order O&P tests reflexively as part of a standard workup for acute diarrhea. From 2001 to 2007, Associated Regional and University Pathologists Laboratories experienced a 379% increase in O&P testing.⁶ Many providers ordering these tests assume that standard O&P testing covers most, if not all, parasites and that a negative test will rule out a parasitic cause of disease. Furthermore, providers are unaware that more sensitive tests to detect certain parasites have replaced standard O&P microscopy.³

Most hospitalized patients do not have a parasitic infection

In a review of 5,681 completed O&P tests from a tertiary care medical center in Canada over a 5-year period, only 1.4% of tests were positive.⁷ In a 3-year retrospective analysis of stool samples obtained after 3 days of hospitalization, positive results were found in only 1 of 191 stool cultures and in 0 of 90 O&P samples.⁸ Current practice guidelines suggest not testing patients with stool studies in cases of acute diarrhea lasting less than 7 days in the absence of significant risk factors for parasitic disease because it has been shown to be a rare event and most cases will self-resolve with supportive care only.^1,9

The stool O&P test has low sensitivity

Classically ordered stool O&P tests have low sensitivity for the detection of Giardia and Cryptosporidium, the two most common parasites in the United States.^6,10,11 O&P studies detect Giardia in only 66% to 79% of specimen samples and Cryptosporidium in less than 5% of specimens. Diagnostic yields can be improved with the use of special stains such as modified acid-fast stain (MAF).⁶ Despite use of MAF staining, though, sensitivity for Cryptosporidium detection has remained at only 55%.¹² Additionally, several studies have shown that physicians are generally unaware of the test characteristics of stool O&P tests and they do not know to order the newer more sensitive enzyme immunoassays (EIA) or direct fluorescent antibody (DFA) tests even in situations when testing for a parasitic infection is appropriate.^10,11,13,14 As stated earlier, a parasitic infection without significant risk factors is a rare event. A negative test with low or moderate sensitivity is not additive to such a low clinical suspicion because it does not significantly change posttest probability.

Testing can have adverse consequences

In addition to the low yield, O&P testing is technically complex, is time intensive, and requires an experienced technician’s interpretation. Inappropriate testing increases the cost of care and staff workload without much benefit.⁶ As such, some institutions have opted to send the O&P tests to labs with experienced technicians. Other institutions have adopted a restrictive stool O&P testing approach that reduces healthcare time and costs and improves the rate of positive tests.^13,15 A study at a single tertiary care medical center demonstrated an estimated cost savings of $21,931 annually by implementing a computer-based algorithm to restrict testing for stool cultures and O&P tests to patients with higher probabilities of infection.¹⁵ The algorithm directed clinicians to provide further information when attempting to order stool culture, O&P, or other specific stool tests. For patients hospitalized for more than 3 days, the system did not allow certain testing. For patients with worrisome features like severe symptoms or an immunocompromised state, the algorithm directed the clinician to place an infectious disease or gastroenterology consult rather than order stool tests. Decreased laboratory costs of all stool studies (including O&P) in adult inpatient locations led to the cost savings. Additionally, the study authors felt that they likely underestimated the cost savings because they did not account for other expenses in the analysis, such as nursing workload and supplies.¹⁵

Clinicians should evaluate patients on a case-by-case basis and determine the need to test based on the presence of high-risk features (Table).

When performing parasitic testing in patients without a recent travel history but with other high-risk features, test for the most prevalent parasites in the United States (ie, Giardia, Cryptosporidium, and Entamoeba histolytica) with DFA or EIA tests.³ DFA testing for Giardia is 99% sensitive.¹² In patients with symptoms lasting more than 7 days and recent travel, in addition to the above DFA/EIA tests, perform O&P testing with wet mount, modified acid-fast bacilli stain to detect rare parasites such as helminths, Strongyloides, Cyclospora, and Cystoisospora.³ In patients who live or travel to endemic areas (about 10% of traveler’s diarrhea is caused by parasitic infections), have unexplained eosinophilia, or are part of a community outbreak (eg, childcare institutions or drinking water/food outbreaks), test for Giardia, Cryptosporidium, Cyclospora, Cystoisospora, Entamoeba histolytica, and Isospora belli.⁹ In addition, among patients with AIDS or immunosuppression, testing should include assays for Microsporidia, Strongyloides, and Mycobacterium avium complex (Figure).^9,16 Newer tests, such as the multiplex real-time polymerase chain reaction assay, can also simultaneously detect Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum. For more information on parasitic testing, we suggest reading the review article “Beyond O&P times three.”³ It is important to familiarize yourself with the parasitic tests available at your respective clinics/hospital so the optimal test can be used.

• Prescribe a trial of “wait and see” for patients without high-risk features for parasitic disease.
• Test patients with high-risk features for parasitic disease by utilizing targeted testing.
• For patients with high-risk features but no travel history, first perform DFA, EIA, or multiplex real-time polymerase chain reaction testing to evaluate for Giardia, Cryptosporidium, and Entamoeba histolytica.
• If DFA/EIA testing is negative, obtain O&P tests with and without stains, such as acid-fast bacilli, for detection of other rare parasites.

Hospitalists should risk-stratify patients to determine when O&P testing is appropriate. Employ more targeted testing, especially use of DFA/EIA tests when evaluating for parasites. Avoid parasitic testing if symptoms have lasted less than 7 days and the patient has no other high-risk features. Become familiar with the tests available at your institution and their sensitivities. As in our clinical scenario, most acute cases of diarrhea resolve without intervention and should be managed and treated conservatively.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason ^™ ” topics by emailing [email protected] .

The authors thank Dr Lenny Feldman for his assistance with editing the manuscript.

Despite the important clinical and public health implications of a COVID-19 diagnosis, respect for autonomy allows patients to decline testing without explanation and with impunity. Whether physicians believe a test is indicated for clinical care of an individual patient, prevention of nosocomial transmission, or the greater public health, patients may refuse. Such refusals may be increasing due to quarantine requirements, concerns regarding contact tracing, and the persistent absence of a curative treatment.^1,2 Mass screening of all healthcare workers (HCWs) is being considered to prevent hospital transmission,³ and universal screening in nursing homes has thwarted outbreaks while providing data to facilitate resource allocation.⁴ Given these circumstances, patients’ absolute right to refuse a noninvasive test with the potential for multifaceted downstream benefit is worthy of reconsideration, in favor of mandatory testing. Mandatory testing confers numerous benefits, including mitigating risk to other patients and HCWs, who play a central role in pandemic response. Because infected HCWs may transmit the virus to patients, they also should undergo mandatory testing,³ particularly in the presence of symptoms, since nasal secretions increase the diagnostic yield of testing.⁵ Although pretest probability (as an estimate of disease prevalence) typically determines the testing strategy for admitted patients, model-based analyses suggest that testing every 3 days for HCWs or continuously hospitalized patients would nearly eliminate infectivity.⁶

Tools for assisting frustrated HCWs navigating patients’ right to refuse testing have been developed that incorporate education, clear communication, and conflict resolution.⁷ Such approaches are, however, only moderately successful, making the use of personal protective equipment (PPE) based on a default assumption of COVID-19 positivity common.⁸ The burden and disheartening waste created by low-yield PPE use among patients unwilling to be tested becomes particularly evident in the context of shortages. Such vexing, stressful shortages, as well as the dual responsibilities of hospitals as stewards of both individual patient and population health, serve as reminders that efficient allocation of resources must be valued alongside the autonomous rights of patients.⁹ Moreover, recent reports suggest that test avoidance is a growing problem.^1,2 Refusal to accept testing may be rooted in anxiety, concerns about the consequences of a positive result (eg, inability to attend school or work), or a desire for self-determination.^1,2 The hesitancy that leads to refusal may also arise from misinformation, poor public health messaging, distrust in the establishment, and unproductive considerations related to conscientious objection without foundation.² Concepts of individual liberty that often underlie steadfast adherence to the principles of self-determination created opposition to masks that antagonized public health efforts to limit the spread of COVID-19. Although influencing inpatients’ behavior to benefit both the public and HCWs may be distinct from community settings, the attitudes that lead to test refusal and defiance of mask-related ordinances likely have substantial commonalities.

As a pillar of ethical decision-making, patient autonomy plays a powerful role in healthcare decisions in the United States. Whereas values such as beneficence, nonmaleficence, advocacy, and distributive justice impact certain decisions, patient autonomy has evolved into the dominant value. Although the beneficence model had historically guided medical decision-making, the bioethics community spearheaded the emergence of the autonomy model during the past several decades.¹⁰ Benevolent deception (ie, therapeutic privilege) and medical paternalism were central features of the beneficence model.¹¹ However, the cornerstone of the autonomy model is informed consent, which provides assurance that patients will be neither deceived nor coerced.¹⁰ Professionalism has always presupposed that the beneficence model would result in decisions directed at both improving patient health and minimizing individual patient harms. The public good and consequent positive externalities were acceptable considerations in decisions based on therapeutic privilege before the autonomy model became dominant. In keeping with the philosophical underpinnings of this approach, advocacy for the public health is still considered a justification for limiting informed consent and breaching confidentiality for disease reporting and contact tracing.⁹

In non-healthcare settings, the controversies surrounding vaccination and access to schools for unvaccinated children are perhaps the public and professional debate most analogous to COVID-19 testing refusal.¹² Although policymakers may distinguish between testing and vaccination, these interventions similarly hold the potential to limit disease incidence and mitigate health impact. To preserve public health, most states prevent (with varied exemptions) unvaccinated children from attending schools. COVID-19 testing may in the future become a requirement for participation in group social activities, athletic competitions, or physical presence in the workplace to facilitate quarantining and/or targeted use of PPE for transmission risk reduction. Given the dramatic mitigation benefits accruable on college campuses,¹³ required testing for in-person learning has become common.

There are also parallels, and therefore lessons, to be drawn from experience in testing for HIV, although HIV-related stigma and devalued status of the marginalized populations initially infected impacted the broader societal view of HIV compared with COVID-19. For example, antenatal HIV screening of pregnant women is strongly recommended to facilitate interventions that reduce the chance of vertical transmission.¹⁴ The limitations of purely elective testing are one justification for the current standard of opt-out screening. However, in this case, the health complications of refusal are largely the burden of the fetus, over whose future the mother holds a great deal of choice and responsibility, irrespective of HIV status. The public health implications of HIV test refusal are far less immediate than for COVID-19 infection because there is no effective curative therapy for COVID-19 and spread occurs through nonintimate, unintentional, and unpredictable exposure.

Translating societal attitudes and practices into the healthcare setting to consider mandated COVID-19 testing requires additional considerations related to both patients and providers: (1) HCWs have committed to a set of values and professional obligations that include tasks requiring risks¹⁵; (2) the public expects HCWs to perform their duties according to a social contract that has few restrictions¹⁶; (3) limiting patient access to hospital care due to COVID-19 testing refusal would contradict and create conflicts related to professional conceptions of hospitals and physicians as patient agents¹⁵; and (4) patients who conscientiously object to testing may seek healthcare less diligently, which may lead to health decrements. The associated postponement of essential care may unduly burden the healthcare system, particularly in situations such as ambulatory care–sensitive conditions.

The extent to which the public health justification for mandatory testing extends to hospitalized patients to protect HCWs is ambiguous. HCWs are of enormous instrumental value and are therefore essential for the pandemic response and health of the broader population. Their protection may therefore justify curtailing informed consent for diagnostic testing. Downstream effects on the supply of frontline HCWs may be realized. Poor control over working conditions may negatively impact motivation among HCWs. In addition, they may feel disenfranchised while obligatorily taking personal risks in caring for patients unwilling to commit to the common good through diagnostic test consent. Hospitalized patients who refuse testing may remain patients under investigation (PUIs), thus requiring special respiratory precautions (SRP) throughout their hospitalization, thereby placing a persistent burden on those with responsibilities requiring patient contact.¹⁷ Repeatedly donning and doffing PPE may remind at-risk HCWs that a myriad of benefits may accrue from frequent, ubiquitous testing. Their motivation may be tempered by the demoralizing requirement to care for patients who will not consent to a simple test, knowing that an opportunity to diminish the burdens of this communicable disease that has taken the lives of many HCWs is being relinquished.

Although HCWs could use SRP universally, their selective application in rooms of known COVID-19–positive patients and those with temporary PUI status has several advantages.¹⁷ First, we learned that HIV testing on patients was helpful in enabling surgeons to selectively implement special precautions among infected patients rather than universally applied intensive precautions. Even in the setting of high rates of HIV infection and educational interventions, HCWs do not reliably apply protective measures included in universal precautions.¹⁸ In keeping with these experiences, limiting the number of patients on SRP will minimize the “precautions fatigue” that drives nonadherent behavior among HCWs.¹⁷ As a result, minimizing the proportion of patients on SRP through testing (and liberation from unnecessary precautions in most cases) will improve uptake of crucial hand hygiene practices and adoption of vigilant PPE use. Second, definitive knowledge of COVID-19 status will increase patient access to care because, whether by personal choice or policy, many HCWs limit in-person contact with patients who are or may be COVID-19 positive. For example, many inpatient dialysis units do not accept patients without a negative COVID-19 nasal swab. Physical therapists may delay or avoid seeing a PUI, which will pose challenges for efficient determination of discharge disposition. Third, selective use of SRP will limit the environmental impact of disposed PPE, which is neither recyclable nor biodegradable. Infectious or regulated biomedical waste products are a significant source of environmental pollution, and the World Health Organization has recommended parsimonious, selective use of PPE to minimize the adverse environmental consequences of biomedical waste products.

In summary, there are substantial justifications for mandatory testing for COVID-19 in the hospital for HCWs and patients, as has been successfully piloted in selected long-term care facilities. Patients who refuse to allow testing may have to accept that their care may be compromised. For preservation of HCW supply and maintenance of HCW morale, hospital policies should make explicit, without punishment or coercion, that HCWs may modify the care they provide to patients who refuse to consent to COVID-19 testing.

Despite the important clinical and public health implications of a COVID-19 diagnosis, respect for autonomy allows patients to decline testing without explanation and with impunity. Whether physicians believe a test is indicated for clinical care of an individual patient, prevention of nosocomial transmission, or the greater public health, patients may refuse. Such refusals may be increasing due to quarantine requirements, concerns regarding contact tracing, and the persistent absence of a curative treatment.^1,2 Mass screening of all healthcare workers (HCWs) is being considered to prevent hospital transmission,³ and universal screening in nursing homes has thwarted outbreaks while providing data to facilitate resource allocation.⁴ Given these circumstances, patients’ absolute right to refuse a noninvasive test with the potential for multifaceted downstream benefit is worthy of reconsideration, in favor of mandatory testing. Mandatory testing confers numerous benefits, including mitigating risk to other patients and HCWs, who play a central role in pandemic response. Because infected HCWs may transmit the virus to patients, they also should undergo mandatory testing,³ particularly in the presence of symptoms, since nasal secretions increase the diagnostic yield of testing.⁵ Although pretest probability (as an estimate of disease prevalence) typically determines the testing strategy for admitted patients, model-based analyses suggest that testing every 3 days for HCWs or continuously hospitalized patients would nearly eliminate infectivity.⁶

Tools for assisting frustrated HCWs navigating patients’ right to refuse testing have been developed that incorporate education, clear communication, and conflict resolution.⁷ Such approaches are, however, only moderately successful, making the use of personal protective equipment (PPE) based on a default assumption of COVID-19 positivity common.⁸ The burden and disheartening waste created by low-yield PPE use among patients unwilling to be tested becomes particularly evident in the context of shortages. Such vexing, stressful shortages, as well as the dual responsibilities of hospitals as stewards of both individual patient and population health, serve as reminders that efficient allocation of resources must be valued alongside the autonomous rights of patients.⁹ Moreover, recent reports suggest that test avoidance is a growing problem.^1,2 Refusal to accept testing may be rooted in anxiety, concerns about the consequences of a positive result (eg, inability to attend school or work), or a desire for self-determination.^1,2 The hesitancy that leads to refusal may also arise from misinformation, poor public health messaging, distrust in the establishment, and unproductive considerations related to conscientious objection without foundation.² Concepts of individual liberty that often underlie steadfast adherence to the principles of self-determination created opposition to masks that antagonized public health efforts to limit the spread of COVID-19. Although influencing inpatients’ behavior to benefit both the public and HCWs may be distinct from community settings, the attitudes that lead to test refusal and defiance of mask-related ordinances likely have substantial commonalities.

As a pillar of ethical decision-making, patient autonomy plays a powerful role in healthcare decisions in the United States. Whereas values such as beneficence, nonmaleficence, advocacy, and distributive justice impact certain decisions, patient autonomy has evolved into the dominant value. Although the beneficence model had historically guided medical decision-making, the bioethics community spearheaded the emergence of the autonomy model during the past several decades.¹⁰ Benevolent deception (ie, therapeutic privilege) and medical paternalism were central features of the beneficence model.¹¹ However, the cornerstone of the autonomy model is informed consent, which provides assurance that patients will be neither deceived nor coerced.¹⁰ Professionalism has always presupposed that the beneficence model would result in decisions directed at both improving patient health and minimizing individual patient harms. The public good and consequent positive externalities were acceptable considerations in decisions based on therapeutic privilege before the autonomy model became dominant. In keeping with the philosophical underpinnings of this approach, advocacy for the public health is still considered a justification for limiting informed consent and breaching confidentiality for disease reporting and contact tracing.⁹

In non-healthcare settings, the controversies surrounding vaccination and access to schools for unvaccinated children are perhaps the public and professional debate most analogous to COVID-19 testing refusal.¹² Although policymakers may distinguish between testing and vaccination, these interventions similarly hold the potential to limit disease incidence and mitigate health impact. To preserve public health, most states prevent (with varied exemptions) unvaccinated children from attending schools. COVID-19 testing may in the future become a requirement for participation in group social activities, athletic competitions, or physical presence in the workplace to facilitate quarantining and/or targeted use of PPE for transmission risk reduction. Given the dramatic mitigation benefits accruable on college campuses,¹³ required testing for in-person learning has become common.

There are also parallels, and therefore lessons, to be drawn from experience in testing for HIV, although HIV-related stigma and devalued status of the marginalized populations initially infected impacted the broader societal view of HIV compared with COVID-19. For example, antenatal HIV screening of pregnant women is strongly recommended to facilitate interventions that reduce the chance of vertical transmission.¹⁴ The limitations of purely elective testing are one justification for the current standard of opt-out screening. However, in this case, the health complications of refusal are largely the burden of the fetus, over whose future the mother holds a great deal of choice and responsibility, irrespective of HIV status. The public health implications of HIV test refusal are far less immediate than for COVID-19 infection because there is no effective curative therapy for COVID-19 and spread occurs through nonintimate, unintentional, and unpredictable exposure.

Translating societal attitudes and practices into the healthcare setting to consider mandated COVID-19 testing requires additional considerations related to both patients and providers: (1) HCWs have committed to a set of values and professional obligations that include tasks requiring risks¹⁵; (2) the public expects HCWs to perform their duties according to a social contract that has few restrictions¹⁶; (3) limiting patient access to hospital care due to COVID-19 testing refusal would contradict and create conflicts related to professional conceptions of hospitals and physicians as patient agents¹⁵; and (4) patients who conscientiously object to testing may seek healthcare less diligently, which may lead to health decrements. The associated postponement of essential care may unduly burden the healthcare system, particularly in situations such as ambulatory care–sensitive conditions.

The extent to which the public health justification for mandatory testing extends to hospitalized patients to protect HCWs is ambiguous. HCWs are of enormous instrumental value and are therefore essential for the pandemic response and health of the broader population. Their protection may therefore justify curtailing informed consent for diagnostic testing. Downstream effects on the supply of frontline HCWs may be realized. Poor control over working conditions may negatively impact motivation among HCWs. In addition, they may feel disenfranchised while obligatorily taking personal risks in caring for patients unwilling to commit to the common good through diagnostic test consent. Hospitalized patients who refuse testing may remain patients under investigation (PUIs), thus requiring special respiratory precautions (SRP) throughout their hospitalization, thereby placing a persistent burden on those with responsibilities requiring patient contact.¹⁷ Repeatedly donning and doffing PPE may remind at-risk HCWs that a myriad of benefits may accrue from frequent, ubiquitous testing. Their motivation may be tempered by the demoralizing requirement to care for patients who will not consent to a simple test, knowing that an opportunity to diminish the burdens of this communicable disease that has taken the lives of many HCWs is being relinquished.

Although HCWs could use SRP universally, their selective application in rooms of known COVID-19–positive patients and those with temporary PUI status has several advantages.¹⁷ First, we learned that HIV testing on patients was helpful in enabling surgeons to selectively implement special precautions among infected patients rather than universally applied intensive precautions. Even in the setting of high rates of HIV infection and educational interventions, HCWs do not reliably apply protective measures included in universal precautions.¹⁸ In keeping with these experiences, limiting the number of patients on SRP will minimize the “precautions fatigue” that drives nonadherent behavior among HCWs.¹⁷ As a result, minimizing the proportion of patients on SRP through testing (and liberation from unnecessary precautions in most cases) will improve uptake of crucial hand hygiene practices and adoption of vigilant PPE use. Second, definitive knowledge of COVID-19 status will increase patient access to care because, whether by personal choice or policy, many HCWs limit in-person contact with patients who are or may be COVID-19 positive. For example, many inpatient dialysis units do not accept patients without a negative COVID-19 nasal swab. Physical therapists may delay or avoid seeing a PUI, which will pose challenges for efficient determination of discharge disposition. Third, selective use of SRP will limit the environmental impact of disposed PPE, which is neither recyclable nor biodegradable. Infectious or regulated biomedical waste products are a significant source of environmental pollution, and the World Health Organization has recommended parsimonious, selective use of PPE to minimize the adverse environmental consequences of biomedical waste products.

In summary, there are substantial justifications for mandatory testing for COVID-19 in the hospital for HCWs and patients, as has been successfully piloted in selected long-term care facilities. Patients who refuse to allow testing may have to accept that their care may be compromised. For preservation of HCW supply and maintenance of HCW morale, hospital policies should make explicit, without punishment or coercion, that HCWs may modify the care they provide to patients who refuse to consent to COVID-19 testing.

Despite the important clinical and public health implications of a COVID-19 diagnosis, respect for autonomy allows patients to decline testing without explanation and with impunity. Whether physicians believe a test is indicated for clinical care of an individual patient, prevention of nosocomial transmission, or the greater public health, patients may refuse. Such refusals may be increasing due to quarantine requirements, concerns regarding contact tracing, and the persistent absence of a curative treatment.^1,2 Mass screening of all healthcare workers (HCWs) is being considered to prevent hospital transmission,³ and universal screening in nursing homes has thwarted outbreaks while providing data to facilitate resource allocation.⁴ Given these circumstances, patients’ absolute right to refuse a noninvasive test with the potential for multifaceted downstream benefit is worthy of reconsideration, in favor of mandatory testing. Mandatory testing confers numerous benefits, including mitigating risk to other patients and HCWs, who play a central role in pandemic response. Because infected HCWs may transmit the virus to patients, they also should undergo mandatory testing,³ particularly in the presence of symptoms, since nasal secretions increase the diagnostic yield of testing.⁵ Although pretest probability (as an estimate of disease prevalence) typically determines the testing strategy for admitted patients, model-based analyses suggest that testing every 3 days for HCWs or continuously hospitalized patients would nearly eliminate infectivity.⁶

Tools for assisting frustrated HCWs navigating patients’ right to refuse testing have been developed that incorporate education, clear communication, and conflict resolution.⁷ Such approaches are, however, only moderately successful, making the use of personal protective equipment (PPE) based on a default assumption of COVID-19 positivity common.⁸ The burden and disheartening waste created by low-yield PPE use among patients unwilling to be tested becomes particularly evident in the context of shortages. Such vexing, stressful shortages, as well as the dual responsibilities of hospitals as stewards of both individual patient and population health, serve as reminders that efficient allocation of resources must be valued alongside the autonomous rights of patients.⁹ Moreover, recent reports suggest that test avoidance is a growing problem.^1,2 Refusal to accept testing may be rooted in anxiety, concerns about the consequences of a positive result (eg, inability to attend school or work), or a desire for self-determination.^1,2 The hesitancy that leads to refusal may also arise from misinformation, poor public health messaging, distrust in the establishment, and unproductive considerations related to conscientious objection without foundation.² Concepts of individual liberty that often underlie steadfast adherence to the principles of self-determination created opposition to masks that antagonized public health efforts to limit the spread of COVID-19. Although influencing inpatients’ behavior to benefit both the public and HCWs may be distinct from community settings, the attitudes that lead to test refusal and defiance of mask-related ordinances likely have substantial commonalities.

As a pillar of ethical decision-making, patient autonomy plays a powerful role in healthcare decisions in the United States. Whereas values such as beneficence, nonmaleficence, advocacy, and distributive justice impact certain decisions, patient autonomy has evolved into the dominant value. Although the beneficence model had historically guided medical decision-making, the bioethics community spearheaded the emergence of the autonomy model during the past several decades.¹⁰ Benevolent deception (ie, therapeutic privilege) and medical paternalism were central features of the beneficence model.¹¹ However, the cornerstone of the autonomy model is informed consent, which provides assurance that patients will be neither deceived nor coerced.¹⁰ Professionalism has always presupposed that the beneficence model would result in decisions directed at both improving patient health and minimizing individual patient harms. The public good and consequent positive externalities were acceptable considerations in decisions based on therapeutic privilege before the autonomy model became dominant. In keeping with the philosophical underpinnings of this approach, advocacy for the public health is still considered a justification for limiting informed consent and breaching confidentiality for disease reporting and contact tracing.⁹

In non-healthcare settings, the controversies surrounding vaccination and access to schools for unvaccinated children are perhaps the public and professional debate most analogous to COVID-19 testing refusal.¹² Although policymakers may distinguish between testing and vaccination, these interventions similarly hold the potential to limit disease incidence and mitigate health impact. To preserve public health, most states prevent (with varied exemptions) unvaccinated children from attending schools. COVID-19 testing may in the future become a requirement for participation in group social activities, athletic competitions, or physical presence in the workplace to facilitate quarantining and/or targeted use of PPE for transmission risk reduction. Given the dramatic mitigation benefits accruable on college campuses,¹³ required testing for in-person learning has become common.

There are also parallels, and therefore lessons, to be drawn from experience in testing for HIV, although HIV-related stigma and devalued status of the marginalized populations initially infected impacted the broader societal view of HIV compared with COVID-19. For example, antenatal HIV screening of pregnant women is strongly recommended to facilitate interventions that reduce the chance of vertical transmission.¹⁴ The limitations of purely elective testing are one justification for the current standard of opt-out screening. However, in this case, the health complications of refusal are largely the burden of the fetus, over whose future the mother holds a great deal of choice and responsibility, irrespective of HIV status. The public health implications of HIV test refusal are far less immediate than for COVID-19 infection because there is no effective curative therapy for COVID-19 and spread occurs through nonintimate, unintentional, and unpredictable exposure.

Translating societal attitudes and practices into the healthcare setting to consider mandated COVID-19 testing requires additional considerations related to both patients and providers: (1) HCWs have committed to a set of values and professional obligations that include tasks requiring risks¹⁵; (2) the public expects HCWs to perform their duties according to a social contract that has few restrictions¹⁶; (3) limiting patient access to hospital care due to COVID-19 testing refusal would contradict and create conflicts related to professional conceptions of hospitals and physicians as patient agents¹⁵; and (4) patients who conscientiously object to testing may seek healthcare less diligently, which may lead to health decrements. The associated postponement of essential care may unduly burden the healthcare system, particularly in situations such as ambulatory care–sensitive conditions.

The extent to which the public health justification for mandatory testing extends to hospitalized patients to protect HCWs is ambiguous. HCWs are of enormous instrumental value and are therefore essential for the pandemic response and health of the broader population. Their protection may therefore justify curtailing informed consent for diagnostic testing. Downstream effects on the supply of frontline HCWs may be realized. Poor control over working conditions may negatively impact motivation among HCWs. In addition, they may feel disenfranchised while obligatorily taking personal risks in caring for patients unwilling to commit to the common good through diagnostic test consent. Hospitalized patients who refuse testing may remain patients under investigation (PUIs), thus requiring special respiratory precautions (SRP) throughout their hospitalization, thereby placing a persistent burden on those with responsibilities requiring patient contact.¹⁷ Repeatedly donning and doffing PPE may remind at-risk HCWs that a myriad of benefits may accrue from frequent, ubiquitous testing. Their motivation may be tempered by the demoralizing requirement to care for patients who will not consent to a simple test, knowing that an opportunity to diminish the burdens of this communicable disease that has taken the lives of many HCWs is being relinquished.

Although HCWs could use SRP universally, their selective application in rooms of known COVID-19–positive patients and those with temporary PUI status has several advantages.¹⁷ First, we learned that HIV testing on patients was helpful in enabling surgeons to selectively implement special precautions among infected patients rather than universally applied intensive precautions. Even in the setting of high rates of HIV infection and educational interventions, HCWs do not reliably apply protective measures included in universal precautions.¹⁸ In keeping with these experiences, limiting the number of patients on SRP will minimize the “precautions fatigue” that drives nonadherent behavior among HCWs.¹⁷ As a result, minimizing the proportion of patients on SRP through testing (and liberation from unnecessary precautions in most cases) will improve uptake of crucial hand hygiene practices and adoption of vigilant PPE use. Second, definitive knowledge of COVID-19 status will increase patient access to care because, whether by personal choice or policy, many HCWs limit in-person contact with patients who are or may be COVID-19 positive. For example, many inpatient dialysis units do not accept patients without a negative COVID-19 nasal swab. Physical therapists may delay or avoid seeing a PUI, which will pose challenges for efficient determination of discharge disposition. Third, selective use of SRP will limit the environmental impact of disposed PPE, which is neither recyclable nor biodegradable. Infectious or regulated biomedical waste products are a significant source of environmental pollution, and the World Health Organization has recommended parsimonious, selective use of PPE to minimize the adverse environmental consequences of biomedical waste products.

In summary, there are substantial justifications for mandatory testing for COVID-19 in the hospital for HCWs and patients, as has been successfully piloted in selected long-term care facilities. Patients who refuse to allow testing may have to accept that their care may be compromised. For preservation of HCW supply and maintenance of HCW morale, hospital policies should make explicit, without punishment or coercion, that HCWs may modify the care they provide to patients who refuse to consent to COVID-19 testing.

In July 2020, the revision of The Pediatric Hospital Medicine Core Competencies was published, bringing to fruition three years of meticulous work.¹ The working group produced 66 chapters outlining the knowledge, skills, and attitudes needed for competent pediatric hospitalist practice. The arrival of these competencies is especially prescient given pediatric hospital medicine’s (PHM’s) relatively new standing as an American Board of Medical Specialties certified subspecialty, as the competencies can serve as a guide for improvement of fellowship curricula, assessment systems, and faculty development. The competencies also represent an opportunity for PHM to take a bold step forward in the world of graduate medical education (GME) by realizing a key tenet of competency-based medical education (CBME)—competency-based, time-variable training (CBTVT), in which learners train until competence is achieved rather than for a predetermined duration.^2,3 In this perspective, we describe how medical education in the United States adopted a time-based training paradigm (in which time-in-training is a surrogate for competence), how CBME has brought time-variable training to the fore, and how PHM has an opportunity to be on the leading edge of education innovation.

In the 1800s, during the time of the “Wild West,” medical education in the United States matched this moniker. There was little standardization across the multiple training pathways to become a practicing physician, including apprenticeships, lecture series, and university courses.⁴ Predictably, this led to significant heterogeneity in the quality of medical care that a patient of the day received. This problem became clearer as Americans traveled to Europe and witnessed more structured and rigorous training programs, only to return to the comparatively poor state of medical education back home.⁵ There was a clear need for curricular standardization.

In 1876, the American Medical College Association (which later became the Association of American Medical Colleges [AAMC]) was founded to meet this need, and in 1905 the Association adopted a set of minimum standards for medical training that included the now-familiar two years of basic sciences and two years of clinical training.⁶ Two subsequent national surveys in the United States were commissioned to evaluate whether medical schools met this new standard, with both surveys finding that roughly half of existing programs passed muster.^7,8 As a result, nearly half of US medical schools had closed by 1920 in a crusade to standardize curricula and produce competent physicians. By the time the American Medical Association established initial standards for internship (an archetype of GME),⁴ time-based medical training was the dominant paradigm. This historical perspective highlights the rationale for standardization of education processes and curricula, particularly in terms of accountability to the American public. But heralded by the 1978 landmark paper by McGaghie et al,⁹ the paradigm began to shift in the late twentieth century from a focus on the process of physician training to outcomes.

In contrast to the process-focused model of the early 1900s, CBME starts by identifying patient and healthcare system needs, defining competencies required to meet those needs, and then designing curricular and assessment processes to help learners achieve those competencies.² This outcomes-based approach grew as a response to calls for greater accountability to the public due to evidence that some graduates were unprepared for unsupervised practice, raising concerns that strictly time-based training was no longer defensible.¹⁰ CBME aims to mitigate these concerns by starting with desired outcomes of training and working backward to ensure those outcomes are met.

While many programs have attempted to implement CBME, most still rely heavily on time-in-training to determine competence. Learners participate in structured curricula and, unless they are extreme outliers, are deemed ready for unsupervised practice after a predetermined duration. This model presumes that competence and time are related in a fixed, predictable manner and that learners gain competence at a uniform rate. However, learners do not, in fact, progress uniformly. A study by Schumacher et al¹¹ involving 23 pediatric residency programs showed significant interlearner variability in rates of entrustment (used as a surrogate for competence), leading the authors to call for time-variable training in GME. Significant interlearner variation in rates of competence attainment have been shown in other specialties as well.¹² As more CBME studies on training outcomes emerge, the evidence is mounting that not all learners need the same duration of training to become competent providers. Time-in-training and competence attainment are not related in a fixed manner. As Dr Jason¹³ wrote in 1969, “By making time a constant, we make achievement a variable.” Variable achievement (competence, outcomes) was the very driver for medical education’s shift to a competency-based approach. If variable competence was not acceptable then, why should it be now? The goal of CBTVT is not shorter training, but rather flexible, individualized training both in terms of content and duration. While this also means some learners may need to extend their training, this should already be part of GME programs that are required to have remediation policies for learners who are not progressing as expected.

Time variability is an oft-cited tenet of CBME,^2,3 but one that is being piloted by relatively few programs in the United States, mostly in undergraduate medical education (UME).^14-16 The Education in Pediatrics Across the Continuum (EPAC), a consortium consisting of four institutions piloting CBTVT in UME,¹⁴ has shown early evidence of feasibility¹⁷ and that UME graduates from CBTVT programs enter residency with levels of competence similar to those of graduates of traditional time-based programs.¹⁸ We believe that PHM can take a step toward truly realizing CBME by implementing CBTVT in fellowship programs.

There are multiple reasons why this is an opportune time for PHM fellowships to consider CBTVT. First, PHM is a relatively new board-certified subspecialty with a recently revised set of core competencies¹ that are likely to catalyze programmatic innovation. A key step in change management is building on previous efforts to generate more change.¹⁹ Programs can leverage the momentum from current and impending change initiatives to innovate and implement CBTVT. Second, the revised PHM competencies provide the first crucial step in implementing a CBME program by defining desired training outcomes necessary to deliver high-quality patient care. With PHM competencies now well defined, programs can focus on developing programs of assessment and corresponding faculty development, which can help deliver valid, defensible decisions about fellow competence.

Finally, PHM has a workforce that can support CBTVT. A major barrier to time-variable training in GME is the need for trainees-as-workforce. In many GME programs, residents and fellows provide a relatively inexpensive, renewable workforce. Trainees’ clinical rotations are often scheduled up to 1 year in advance to ensure care teams are fully staffed, particularly in the inpatient setting, creating a system where flexibility in training is impossible without creating gaps in clinical coverage. However, many PHM fellowships do not completely rely on fellows to cover clinical service lines. PHM fellows spend 32 weeks over 2 years in core clinical rotations with faculty supervision, in accordance with the Accreditation Council for Graduate Medical Education program requirements, both for 2- and 3-year programs. Some CBME experts estimate (based on previous and ongoing CBTVT pilots) that training duration is likely to vary by roughly 20% from current time-based practices when CBTVT is initially implemented.²⁰ Thus, only a small number of clinical service weeks are likely to be affected. If a fellow were deemed ready for unsupervised practice before finishing 2 years of fellowship in a CBTVT program, the corresponding faculty supervisor could use the time previously assigned for supervision to pursue other priorities, such as education, scholarship, or quality improvement. Why provide supervision if a clinical competency committee has deemed a fellow ready for unsupervised practice? Some level of observation and formative feedback could continue, but full supervision would be redundant and unnecessary. CBTVT would allow for some fellows to experience the uncertainty that comes with unsupervised decision-making while still in an environment with trusted fellowship mentors and advisors.

PHM fellowship programs likely cannot flip a switch to “turn on” CBTVT immediately, but they can take steps toward making the transition. Validity, or defensibility of decisions, will be crucial for assessment in CBTVT systems. Programs will need to develop robust assessment systems that collect myriad data to answer the question, “When is this learner competent to deliver high-quality care without supervision?” Programs can align assessment instruments, faculty-development initiatives, and clinical competency committee (CCC) processes with the 2020 PHM competencies to provide a defensible answer. Program leaders should then seek validity evidence, either in existing literature or through novel scholarly initiatives, to support these summative decisions. Engaging all fellowship stakeholders in transitions to CBTVT will be important and should include fellows, program directors, CCC members, clinical leadership, and members from accrediting and credentialing bodies.

As fellowship programs review and revise curricula and assessment systems around the updated PHM core competencies, they should also consider what changes are necessary to implement CBTVT. Time variability is not a novelty but, rather, is a corollary to the outcomes-based approach of CBME. PHM fellowships should strike while the iron is hot and build on current change initiatives prompted by the growth of our specialty to be leaders in CBTVT.

In July 2020, the revision of The Pediatric Hospital Medicine Core Competencies was published, bringing to fruition three years of meticulous work.¹ The working group produced 66 chapters outlining the knowledge, skills, and attitudes needed for competent pediatric hospitalist practice. The arrival of these competencies is especially prescient given pediatric hospital medicine’s (PHM’s) relatively new standing as an American Board of Medical Specialties certified subspecialty, as the competencies can serve as a guide for improvement of fellowship curricula, assessment systems, and faculty development. The competencies also represent an opportunity for PHM to take a bold step forward in the world of graduate medical education (GME) by realizing a key tenet of competency-based medical education (CBME)—competency-based, time-variable training (CBTVT), in which learners train until competence is achieved rather than for a predetermined duration.^2,3 In this perspective, we describe how medical education in the United States adopted a time-based training paradigm (in which time-in-training is a surrogate for competence), how CBME has brought time-variable training to the fore, and how PHM has an opportunity to be on the leading edge of education innovation.

In the 1800s, during the time of the “Wild West,” medical education in the United States matched this moniker. There was little standardization across the multiple training pathways to become a practicing physician, including apprenticeships, lecture series, and university courses.⁴ Predictably, this led to significant heterogeneity in the quality of medical care that a patient of the day received. This problem became clearer as Americans traveled to Europe and witnessed more structured and rigorous training programs, only to return to the comparatively poor state of medical education back home.⁵ There was a clear need for curricular standardization.

In 1876, the American Medical College Association (which later became the Association of American Medical Colleges [AAMC]) was founded to meet this need, and in 1905 the Association adopted a set of minimum standards for medical training that included the now-familiar two years of basic sciences and two years of clinical training.⁶ Two subsequent national surveys in the United States were commissioned to evaluate whether medical schools met this new standard, with both surveys finding that roughly half of existing programs passed muster.^7,8 As a result, nearly half of US medical schools had closed by 1920 in a crusade to standardize curricula and produce competent physicians. By the time the American Medical Association established initial standards for internship (an archetype of GME),⁴ time-based medical training was the dominant paradigm. This historical perspective highlights the rationale for standardization of education processes and curricula, particularly in terms of accountability to the American public. But heralded by the 1978 landmark paper by McGaghie et al,⁹ the paradigm began to shift in the late twentieth century from a focus on the process of physician training to outcomes.

In contrast to the process-focused model of the early 1900s, CBME starts by identifying patient and healthcare system needs, defining competencies required to meet those needs, and then designing curricular and assessment processes to help learners achieve those competencies.² This outcomes-based approach grew as a response to calls for greater accountability to the public due to evidence that some graduates were unprepared for unsupervised practice, raising concerns that strictly time-based training was no longer defensible.¹⁰ CBME aims to mitigate these concerns by starting with desired outcomes of training and working backward to ensure those outcomes are met.

While many programs have attempted to implement CBME, most still rely heavily on time-in-training to determine competence. Learners participate in structured curricula and, unless they are extreme outliers, are deemed ready for unsupervised practice after a predetermined duration. This model presumes that competence and time are related in a fixed, predictable manner and that learners gain competence at a uniform rate. However, learners do not, in fact, progress uniformly. A study by Schumacher et al¹¹ involving 23 pediatric residency programs showed significant interlearner variability in rates of entrustment (used as a surrogate for competence), leading the authors to call for time-variable training in GME. Significant interlearner variation in rates of competence attainment have been shown in other specialties as well.¹² As more CBME studies on training outcomes emerge, the evidence is mounting that not all learners need the same duration of training to become competent providers. Time-in-training and competence attainment are not related in a fixed manner. As Dr Jason¹³ wrote in 1969, “By making time a constant, we make achievement a variable.” Variable achievement (competence, outcomes) was the very driver for medical education’s shift to a competency-based approach. If variable competence was not acceptable then, why should it be now? The goal of CBTVT is not shorter training, but rather flexible, individualized training both in terms of content and duration. While this also means some learners may need to extend their training, this should already be part of GME programs that are required to have remediation policies for learners who are not progressing as expected.

Time variability is an oft-cited tenet of CBME,^2,3 but one that is being piloted by relatively few programs in the United States, mostly in undergraduate medical education (UME).^14-16 The Education in Pediatrics Across the Continuum (EPAC), a consortium consisting of four institutions piloting CBTVT in UME,¹⁴ has shown early evidence of feasibility¹⁷ and that UME graduates from CBTVT programs enter residency with levels of competence similar to those of graduates of traditional time-based programs.¹⁸ We believe that PHM can take a step toward truly realizing CBME by implementing CBTVT in fellowship programs.

There are multiple reasons why this is an opportune time for PHM fellowships to consider CBTVT. First, PHM is a relatively new board-certified subspecialty with a recently revised set of core competencies¹ that are likely to catalyze programmatic innovation. A key step in change management is building on previous efforts to generate more change.¹⁹ Programs can leverage the momentum from current and impending change initiatives to innovate and implement CBTVT. Second, the revised PHM competencies provide the first crucial step in implementing a CBME program by defining desired training outcomes necessary to deliver high-quality patient care. With PHM competencies now well defined, programs can focus on developing programs of assessment and corresponding faculty development, which can help deliver valid, defensible decisions about fellow competence.

Finally, PHM has a workforce that can support CBTVT. A major barrier to time-variable training in GME is the need for trainees-as-workforce. In many GME programs, residents and fellows provide a relatively inexpensive, renewable workforce. Trainees’ clinical rotations are often scheduled up to 1 year in advance to ensure care teams are fully staffed, particularly in the inpatient setting, creating a system where flexibility in training is impossible without creating gaps in clinical coverage. However, many PHM fellowships do not completely rely on fellows to cover clinical service lines. PHM fellows spend 32 weeks over 2 years in core clinical rotations with faculty supervision, in accordance with the Accreditation Council for Graduate Medical Education program requirements, both for 2- and 3-year programs. Some CBME experts estimate (based on previous and ongoing CBTVT pilots) that training duration is likely to vary by roughly 20% from current time-based practices when CBTVT is initially implemented.²⁰ Thus, only a small number of clinical service weeks are likely to be affected. If a fellow were deemed ready for unsupervised practice before finishing 2 years of fellowship in a CBTVT program, the corresponding faculty supervisor could use the time previously assigned for supervision to pursue other priorities, such as education, scholarship, or quality improvement. Why provide supervision if a clinical competency committee has deemed a fellow ready for unsupervised practice? Some level of observation and formative feedback could continue, but full supervision would be redundant and unnecessary. CBTVT would allow for some fellows to experience the uncertainty that comes with unsupervised decision-making while still in an environment with trusted fellowship mentors and advisors.

PHM fellowship programs likely cannot flip a switch to “turn on” CBTVT immediately, but they can take steps toward making the transition. Validity, or defensibility of decisions, will be crucial for assessment in CBTVT systems. Programs will need to develop robust assessment systems that collect myriad data to answer the question, “When is this learner competent to deliver high-quality care without supervision?” Programs can align assessment instruments, faculty-development initiatives, and clinical competency committee (CCC) processes with the 2020 PHM competencies to provide a defensible answer. Program leaders should then seek validity evidence, either in existing literature or through novel scholarly initiatives, to support these summative decisions. Engaging all fellowship stakeholders in transitions to CBTVT will be important and should include fellows, program directors, CCC members, clinical leadership, and members from accrediting and credentialing bodies.

As fellowship programs review and revise curricula and assessment systems around the updated PHM core competencies, they should also consider what changes are necessary to implement CBTVT. Time variability is not a novelty but, rather, is a corollary to the outcomes-based approach of CBME. PHM fellowships should strike while the iron is hot and build on current change initiatives prompted by the growth of our specialty to be leaders in CBTVT.

In July 2020, the revision of The Pediatric Hospital Medicine Core Competencies was published, bringing to fruition three years of meticulous work.¹ The working group produced 66 chapters outlining the knowledge, skills, and attitudes needed for competent pediatric hospitalist practice. The arrival of these competencies is especially prescient given pediatric hospital medicine’s (PHM’s) relatively new standing as an American Board of Medical Specialties certified subspecialty, as the competencies can serve as a guide for improvement of fellowship curricula, assessment systems, and faculty development. The competencies also represent an opportunity for PHM to take a bold step forward in the world of graduate medical education (GME) by realizing a key tenet of competency-based medical education (CBME)—competency-based, time-variable training (CBTVT), in which learners train until competence is achieved rather than for a predetermined duration.^2,3 In this perspective, we describe how medical education in the United States adopted a time-based training paradigm (in which time-in-training is a surrogate for competence), how CBME has brought time-variable training to the fore, and how PHM has an opportunity to be on the leading edge of education innovation.

In the 1800s, during the time of the “Wild West,” medical education in the United States matched this moniker. There was little standardization across the multiple training pathways to become a practicing physician, including apprenticeships, lecture series, and university courses.⁴ Predictably, this led to significant heterogeneity in the quality of medical care that a patient of the day received. This problem became clearer as Americans traveled to Europe and witnessed more structured and rigorous training programs, only to return to the comparatively poor state of medical education back home.⁵ There was a clear need for curricular standardization.

In 1876, the American Medical College Association (which later became the Association of American Medical Colleges [AAMC]) was founded to meet this need, and in 1905 the Association adopted a set of minimum standards for medical training that included the now-familiar two years of basic sciences and two years of clinical training.⁶ Two subsequent national surveys in the United States were commissioned to evaluate whether medical schools met this new standard, with both surveys finding that roughly half of existing programs passed muster.^7,8 As a result, nearly half of US medical schools had closed by 1920 in a crusade to standardize curricula and produce competent physicians. By the time the American Medical Association established initial standards for internship (an archetype of GME),⁴ time-based medical training was the dominant paradigm. This historical perspective highlights the rationale for standardization of education processes and curricula, particularly in terms of accountability to the American public. But heralded by the 1978 landmark paper by McGaghie et al,⁹ the paradigm began to shift in the late twentieth century from a focus on the process of physician training to outcomes.

In contrast to the process-focused model of the early 1900s, CBME starts by identifying patient and healthcare system needs, defining competencies required to meet those needs, and then designing curricular and assessment processes to help learners achieve those competencies.² This outcomes-based approach grew as a response to calls for greater accountability to the public due to evidence that some graduates were unprepared for unsupervised practice, raising concerns that strictly time-based training was no longer defensible.¹⁰ CBME aims to mitigate these concerns by starting with desired outcomes of training and working backward to ensure those outcomes are met.

While many programs have attempted to implement CBME, most still rely heavily on time-in-training to determine competence. Learners participate in structured curricula and, unless they are extreme outliers, are deemed ready for unsupervised practice after a predetermined duration. This model presumes that competence and time are related in a fixed, predictable manner and that learners gain competence at a uniform rate. However, learners do not, in fact, progress uniformly. A study by Schumacher et al¹¹ involving 23 pediatric residency programs showed significant interlearner variability in rates of entrustment (used as a surrogate for competence), leading the authors to call for time-variable training in GME. Significant interlearner variation in rates of competence attainment have been shown in other specialties as well.¹² As more CBME studies on training outcomes emerge, the evidence is mounting that not all learners need the same duration of training to become competent providers. Time-in-training and competence attainment are not related in a fixed manner. As Dr Jason¹³ wrote in 1969, “By making time a constant, we make achievement a variable.” Variable achievement (competence, outcomes) was the very driver for medical education’s shift to a competency-based approach. If variable competence was not acceptable then, why should it be now? The goal of CBTVT is not shorter training, but rather flexible, individualized training both in terms of content and duration. While this also means some learners may need to extend their training, this should already be part of GME programs that are required to have remediation policies for learners who are not progressing as expected.

Time variability is an oft-cited tenet of CBME,^2,3 but one that is being piloted by relatively few programs in the United States, mostly in undergraduate medical education (UME).^14-16 The Education in Pediatrics Across the Continuum (EPAC), a consortium consisting of four institutions piloting CBTVT in UME,¹⁴ has shown early evidence of feasibility¹⁷ and that UME graduates from CBTVT programs enter residency with levels of competence similar to those of graduates of traditional time-based programs.¹⁸ We believe that PHM can take a step toward truly realizing CBME by implementing CBTVT in fellowship programs.

There are multiple reasons why this is an opportune time for PHM fellowships to consider CBTVT. First, PHM is a relatively new board-certified subspecialty with a recently revised set of core competencies¹ that are likely to catalyze programmatic innovation. A key step in change management is building on previous efforts to generate more change.¹⁹ Programs can leverage the momentum from current and impending change initiatives to innovate and implement CBTVT. Second, the revised PHM competencies provide the first crucial step in implementing a CBME program by defining desired training outcomes necessary to deliver high-quality patient care. With PHM competencies now well defined, programs can focus on developing programs of assessment and corresponding faculty development, which can help deliver valid, defensible decisions about fellow competence.

Finally, PHM has a workforce that can support CBTVT. A major barrier to time-variable training in GME is the need for trainees-as-workforce. In many GME programs, residents and fellows provide a relatively inexpensive, renewable workforce. Trainees’ clinical rotations are often scheduled up to 1 year in advance to ensure care teams are fully staffed, particularly in the inpatient setting, creating a system where flexibility in training is impossible without creating gaps in clinical coverage. However, many PHM fellowships do not completely rely on fellows to cover clinical service lines. PHM fellows spend 32 weeks over 2 years in core clinical rotations with faculty supervision, in accordance with the Accreditation Council for Graduate Medical Education program requirements, both for 2- and 3-year programs. Some CBME experts estimate (based on previous and ongoing CBTVT pilots) that training duration is likely to vary by roughly 20% from current time-based practices when CBTVT is initially implemented.²⁰ Thus, only a small number of clinical service weeks are likely to be affected. If a fellow were deemed ready for unsupervised practice before finishing 2 years of fellowship in a CBTVT program, the corresponding faculty supervisor could use the time previously assigned for supervision to pursue other priorities, such as education, scholarship, or quality improvement. Why provide supervision if a clinical competency committee has deemed a fellow ready for unsupervised practice? Some level of observation and formative feedback could continue, but full supervision would be redundant and unnecessary. CBTVT would allow for some fellows to experience the uncertainty that comes with unsupervised decision-making while still in an environment with trusted fellowship mentors and advisors.

PHM fellowship programs likely cannot flip a switch to “turn on” CBTVT immediately, but they can take steps toward making the transition. Validity, or defensibility of decisions, will be crucial for assessment in CBTVT systems. Programs will need to develop robust assessment systems that collect myriad data to answer the question, “When is this learner competent to deliver high-quality care without supervision?” Programs can align assessment instruments, faculty-development initiatives, and clinical competency committee (CCC) processes with the 2020 PHM competencies to provide a defensible answer. Program leaders should then seek validity evidence, either in existing literature or through novel scholarly initiatives, to support these summative decisions. Engaging all fellowship stakeholders in transitions to CBTVT will be important and should include fellows, program directors, CCC members, clinical leadership, and members from accrediting and credentialing bodies.

As fellowship programs review and revise curricula and assessment systems around the updated PHM core competencies, they should also consider what changes are necessary to implement CBTVT. Time variability is not a novelty but, rather, is a corollary to the outcomes-based approach of CBME. PHM fellowships should strike while the iron is hot and build on current change initiatives prompted by the growth of our specialty to be leaders in CBTVT.

The healthcare system in South Korea (Korea) is evolving. Korea began developing a national health insurance system for the entire population in 1989, and implementation took 12 years. The healthcare insurance premium was set in 1989 when the Korean gross domestic product (GDP) per capita was less than $5,000 USD. Since then, the incremental rise in healthcare insurance premiums, approximately 6% of the typical Korean income, has been relatively small considering the economic growth of Korea.^1-3 The success and rapid adoption of national health insurance in Korea revealed unanticipated problems in three specific areas: low individual contributions relative to costs of care, low levels of reimbursement to providers, and incomplete coverage of medical services, which then require out-of-pocket payments (typically 20% of the inpatient care fee).⁴ Additionally, while little attention has been paid to quality and safety in the past, the nation has come to recognize the importance of these considerations,⁵ particularly with regard to patient expectations for and consumption of medical care and the consequent demand for better services from the medical community and government.⁶

Healthcare constitutes about 7.5% of Korea’s GDP. In contrast, healthcare spending accounts for about 17.7% of US GDP and about 8.8% of the GDP of member nations of the Organisation for Economic Co-operation and Development (OECD) in aggregate. Additionally, Korea has a longer length of hospital stay (16.5 days vs 7.3 days for OECD countries) and fewer practicing physicians (1.1 per 1,000 persons vs 1.9 per 1,000 for OECD countries). Therefore, the average cumulative annual patient hospital days per physician is 2,394 days in Korea, three times higher than that in the OECD countries.⁷ Furthermore, the number of physicians providing hospital care in Korea has remained relatively low.⁸

Despite recent growth in the total number of practicing physicians, the number of hospital-based physicians remains insufficient to cover admitted patients. The pressure for hospital-based physicians to serve large numbers of patients to generate sufficient revenue has deterred growth of more physicians focused on inpatient care.⁶ In order to operate the hospital, doctors must see as many patients as possible because physicians are reimbursed primarily by an inpatient care fee rather than by type or extent of care provided. Therefore, this low fee schedule makes it difficult to provide good quality inpatient care while simultaneously trying to increase accessibility. The costs of testing and treatment are reimbursed through a separate fee schedule.

The Korean government enacted two new policies regarding medical school graduates and residents that led to implementation of a hospitalist system. The first policy created a quota of medical residents to match the total number of medical school graduates.⁹ Before the new regulation, the number of medical resident positions exceeded the number of medical school graduates by 20%, which led to a shortage of resident applicants in “unpopular” medical specialties or departments. These specialties (eg, general surgery, obstetrics and gynecology, urology) have a lower fee schedule, which leads to lower wages while having very high workloads. The decrease in the number of available medical resident positions results in greater workloads for physicians providing inpatient care. These changes, including the shortage of a resident workforce, led to a burgeoning hospital-based attending physician workforce to care for hospitalized patients.

The other policy, created in December 2015 and known as the Act on the Improvement of Training Conditions and Status of Medical Residents, was enacted to improve working conditions for residents by limiting their working hours to 80 or fewer per week.¹⁰ These work-hour restrictions made it nearly impossible to provide 24-hour inpatient care depending solely on residents.^10-12 This policy increased the need for hospitalists in Korea, similar to that of the US Accreditation Council for Graduate Medical Education in 2003, which limited resident work hours. Because of these changes, the hospitalist model was introduced to manage the growing volume of inpatients at teaching hospitals.¹³

The institutional implementation of the Korean hospitalist system was catalyzed by the need to solve current problems such as patient safety, healthcare quality, and residents’ well-being.^8,14 Therefore, the hospitalist system was designed and implemented to meet the needs of patients, medical professionals, and hospitals.^6,8,14 Furthermore, under the universal health insurance system in Korea, institutional implementation also meant creating a new set of fee schedules for hospitalists. The Korean hospitalist system reflects the nuances and challenges faced by the Korean healthcare system.⁵

A council was formed to implement a hospitalist model suitable for Korea. The council was composed of five groups: the Korean Association of Internal Medicine, Korean Surgical Society, Korean Medical Association, Korean Hospital Association, and Korean Academy of Medical Sciences. The Korean Association of Internal Medicine and the Korean Surgical Society were involved in creating a new medical discipline because their members provided a disproportionate amount of inpatient care and were most often responsible for hospital patient safety and quality care. Along with the support of the council, the Ministry of Health and Welfare began to realize the high demand on inpatient care and requested an official proposal to broaden the hospitalist model, with two conditions. First, the government requested a unified proposal from the medical community that reflected the collective voices of individual stakeholders, with an expectation that the new system would focus on patient safety and healthcare quality across all specialties. Second, the proposal had to be detailed and include a specific fee schedule for hospitalist services.

Before implementing a national hospitalist system, we conducted a pilot study supported by funding from the council. This first study, the Korean Hospitalist System Operation and Evaluation Research (September 2015 to August 2016)¹⁴, was designed to (a) determine hospitalist needs (eg, rotation schedule, salary, working conditions) for this new profession, (b) determine the necessary number of hospitalists and appropriate fee schedules to cover salary and benefits, and (c) provide Korean hospitalist models with operational methods to facilitate implementation at individual institutions. The council and research team selected four hospitals for the privately funded pilot study (Table). These hospitals already had an inpatient care system managed by specialists prior to the pilot study, so major changes in patient care and hospital operations were not required.

The pilot study demonstrated improvements in patient satisfaction, medical service quality, and patient safety.^8,14,15 As a result, fees billed from hospitalist services were now covered by national health insurance; previously, they were not covered by any inpatient care fee or bundled service fee. The next study (phase 2) was then conducted to evaluate the national implementation of the hospitalist system and its outcomes. The first phase defined criteria for monitoring and evaluating the institutionalized hospitalist system in Korea. The second phase, initiated in September 2016, evaluated how the implemented system could be expanded nationwide. The government was actively involved in the study; 31 of 344 (9%) general hospitals were selected and able to apply the hospitalist fee schedule for care of patients who were admitted to the hospitalist ward.

To investigate the effect of the hospitalist system, we measured the satisfaction of patients and medical providers (eg, specialists, residents, and nurses). The outcomes were number of doctors’ calls to hospitalists and to other specialties, duration of time required to address medical problems, number of contacts with the hospitalist (residents or other physicians in the control group), and time spent with hospitalized patients. In addition, we analyzed claims costs and the operating costs for implementing the system within each hospital (Table).

The new set of fee schedules was created specifically for hospitalist care services so hospitals could now claim separate inpatient care fees and hospitalist fees. The standard hospitalist fee schedule is applied only to patients who are on hospitalist-led wards. The fee schedule has two criteria: The hospitalist ward must have 50 beds which are assigned to hospitalists only, and each hospitalist ward has a team of five hospitalists. A maximum of 25 patients could be assigned to an individual hospitalist. However, fees can be adjusted based on individual hospital operation and management after government approval.

Under the national insurance system, the fee schedule is essential to obtain reimbursement for provided services. As a new medical profession, it is important to have the institutional implementation of the hospitalist system. In contrast to those in the United States, inpatients in Korea pay inpatient care fees only, which are charged per day. Therefore, reducing the length of stay without increasing patient volume does not financially benefit the hospital.

The definition of a Korean hospitalist was carefully developed, and a reimbursement system for hospitalists was created within the Korean healthcare system. All hospitalists are medical specialists who have completed advanced education and clinical training in their specialty area (internal medicine or surgery). Creating a definition of a hospitalist and a standard fee schedule was necessary for national incorporation of this new approach. The model must also be accepted by related parties, including healthcare professionals such as hospital executives, nonhospitalist doctors, and nurses. Therefore, the system has a minimum of two requirements to operate at the hospital level, and the remaining factors can be modified by individual hospitals to protect the new discipline within the healthcare system. First, hospitalist services are provided only to hospitalist patients. To establish the new system, limiting the patient range to a specific group was necessary to prevent abuse of human-based resources within the hospital. Second, hospitalists must be stationed near the hospitalist ward to enhance accessibility, patient safety, and healthcare quality. In other words, a hospitalist provides services to hospitalized patients who paid the hospitalist fee, and the hospitalist does not provide care beyond the hospitalist ward (eg, they cannot provide outpatient consultation or provide care on other wards).

Korean national health insurance is the universal health insurance under a single insurer (ie, the government). Therefore, all Korean citizens have national health insurance. Individuals can choose to have additional health insurance (private insurance) if they wish to pay an out-of-pocket fee with their additional private insurance. In Korea, the inpatient care fee includes all fees to provide care for the patient during hospital stays, such as the physician fee, facility fee, and consultation fee. The inpatient care fee schedule is charged per day including all the inpatient care composition. The claim and reimbursement system is different in Korea in that the hospital as a whole submits the claim for reimbursement. There is no separate claim from physicians, lab technicians, or facilities. Doctors provide care to patients and are then paid for the services in terms of salaries. Since the original inpatient care fee schedule was low and insufficient, it was difficult to provide high-quality care. Also, resources for spending on inpatient care management was limited. So a new system to improve inpatient care was needed. Implementing the hospitalist system in Korea led to the creation of a new fee schedule specifically for hospitalists so that hospitals could claim hospitalist fees on top of inpatient care fees when the patient was cared for by the hospitalist. The additional fees in the hospitalist fee schedule allow safe and high-quality care to be provided for patients during hospital stays.

The Korean hospitalist system has been implemented for 3 years with the government’s active involvement, with approximately 250 specialists working as hospitalists as of August 2020. Importantly, Korean hospitalists are not limited to internal medicine specialists; in fact, several different specialties practice as hospitalists, including surgeons and other medical specialists, who account for 20% and 30% of the hospitalist workforce, respectively. Since the system’s implementation, all inpatient care and management is now transferred to specialists from residents in hospitalist wards. This change has increased patient safety and care quality. At the beginning of the pilot study, the concept of a “hospitalist” was new in Korea and the public did not know who a hospitalist was nor what a hospitalist did. However, after 3 years, patients now seek hospitalist care.

National implementation of the hospitalist model represents a key paradigm shift in the Korean healthcare system. The Korean hospitalist system is the result of the hospitals’, doctors’, and patients’ desire for higher-quality care. We expect to see growth of hospitalists in Korea and provision of better, safer, and more efficient inpatient care across specialties, payers, and government. Since we are at the early stage of the system, further efforts to support implementation are required. We hope our implementation process of a new medical system could serve as a model for other countries who are seeking to adopt hospitalist systems within their current healthcare paradigms.

The authors thank the medical professionals, government officers, and other professionals who put great effort into the implementation of the Korean Hospitalist System.

The healthcare system in South Korea (Korea) is evolving. Korea began developing a national health insurance system for the entire population in 1989, and implementation took 12 years. The healthcare insurance premium was set in 1989 when the Korean gross domestic product (GDP) per capita was less than $5,000 USD. Since then, the incremental rise in healthcare insurance premiums, approximately 6% of the typical Korean income, has been relatively small considering the economic growth of Korea.^1-3 The success and rapid adoption of national health insurance in Korea revealed unanticipated problems in three specific areas: low individual contributions relative to costs of care, low levels of reimbursement to providers, and incomplete coverage of medical services, which then require out-of-pocket payments (typically 20% of the inpatient care fee).⁴ Additionally, while little attention has been paid to quality and safety in the past, the nation has come to recognize the importance of these considerations,⁵ particularly with regard to patient expectations for and consumption of medical care and the consequent demand for better services from the medical community and government.⁶

Healthcare constitutes about 7.5% of Korea’s GDP. In contrast, healthcare spending accounts for about 17.7% of US GDP and about 8.8% of the GDP of member nations of the Organisation for Economic Co-operation and Development (OECD) in aggregate. Additionally, Korea has a longer length of hospital stay (16.5 days vs 7.3 days for OECD countries) and fewer practicing physicians (1.1 per 1,000 persons vs 1.9 per 1,000 for OECD countries). Therefore, the average cumulative annual patient hospital days per physician is 2,394 days in Korea, three times higher than that in the OECD countries.⁷ Furthermore, the number of physicians providing hospital care in Korea has remained relatively low.⁸

Despite recent growth in the total number of practicing physicians, the number of hospital-based physicians remains insufficient to cover admitted patients. The pressure for hospital-based physicians to serve large numbers of patients to generate sufficient revenue has deterred growth of more physicians focused on inpatient care.⁶ In order to operate the hospital, doctors must see as many patients as possible because physicians are reimbursed primarily by an inpatient care fee rather than by type or extent of care provided. Therefore, this low fee schedule makes it difficult to provide good quality inpatient care while simultaneously trying to increase accessibility. The costs of testing and treatment are reimbursed through a separate fee schedule.

The Korean government enacted two new policies regarding medical school graduates and residents that led to implementation of a hospitalist system. The first policy created a quota of medical residents to match the total number of medical school graduates.⁹ Before the new regulation, the number of medical resident positions exceeded the number of medical school graduates by 20%, which led to a shortage of resident applicants in “unpopular” medical specialties or departments. These specialties (eg, general surgery, obstetrics and gynecology, urology) have a lower fee schedule, which leads to lower wages while having very high workloads. The decrease in the number of available medical resident positions results in greater workloads for physicians providing inpatient care. These changes, including the shortage of a resident workforce, led to a burgeoning hospital-based attending physician workforce to care for hospitalized patients.

The other policy, created in December 2015 and known as the Act on the Improvement of Training Conditions and Status of Medical Residents, was enacted to improve working conditions for residents by limiting their working hours to 80 or fewer per week.¹⁰ These work-hour restrictions made it nearly impossible to provide 24-hour inpatient care depending solely on residents.^10-12 This policy increased the need for hospitalists in Korea, similar to that of the US Accreditation Council for Graduate Medical Education in 2003, which limited resident work hours. Because of these changes, the hospitalist model was introduced to manage the growing volume of inpatients at teaching hospitals.¹³

The institutional implementation of the Korean hospitalist system was catalyzed by the need to solve current problems such as patient safety, healthcare quality, and residents’ well-being.^8,14 Therefore, the hospitalist system was designed and implemented to meet the needs of patients, medical professionals, and hospitals.^6,8,14 Furthermore, under the universal health insurance system in Korea, institutional implementation also meant creating a new set of fee schedules for hospitalists. The Korean hospitalist system reflects the nuances and challenges faced by the Korean healthcare system.⁵

A council was formed to implement a hospitalist model suitable for Korea. The council was composed of five groups: the Korean Association of Internal Medicine, Korean Surgical Society, Korean Medical Association, Korean Hospital Association, and Korean Academy of Medical Sciences. The Korean Association of Internal Medicine and the Korean Surgical Society were involved in creating a new medical discipline because their members provided a disproportionate amount of inpatient care and were most often responsible for hospital patient safety and quality care. Along with the support of the council, the Ministry of Health and Welfare began to realize the high demand on inpatient care and requested an official proposal to broaden the hospitalist model, with two conditions. First, the government requested a unified proposal from the medical community that reflected the collective voices of individual stakeholders, with an expectation that the new system would focus on patient safety and healthcare quality across all specialties. Second, the proposal had to be detailed and include a specific fee schedule for hospitalist services.

Before implementing a national hospitalist system, we conducted a pilot study supported by funding from the council. This first study, the Korean Hospitalist System Operation and Evaluation Research (September 2015 to August 2016)¹⁴, was designed to (a) determine hospitalist needs (eg, rotation schedule, salary, working conditions) for this new profession, (b) determine the necessary number of hospitalists and appropriate fee schedules to cover salary and benefits, and (c) provide Korean hospitalist models with operational methods to facilitate implementation at individual institutions. The council and research team selected four hospitals for the privately funded pilot study (Table). These hospitals already had an inpatient care system managed by specialists prior to the pilot study, so major changes in patient care and hospital operations were not required.

The pilot study demonstrated improvements in patient satisfaction, medical service quality, and patient safety.^8,14,15 As a result, fees billed from hospitalist services were now covered by national health insurance; previously, they were not covered by any inpatient care fee or bundled service fee. The next study (phase 2) was then conducted to evaluate the national implementation of the hospitalist system and its outcomes. The first phase defined criteria for monitoring and evaluating the institutionalized hospitalist system in Korea. The second phase, initiated in September 2016, evaluated how the implemented system could be expanded nationwide. The government was actively involved in the study; 31 of 344 (9%) general hospitals were selected and able to apply the hospitalist fee schedule for care of patients who were admitted to the hospitalist ward.

To investigate the effect of the hospitalist system, we measured the satisfaction of patients and medical providers (eg, specialists, residents, and nurses). The outcomes were number of doctors’ calls to hospitalists and to other specialties, duration of time required to address medical problems, number of contacts with the hospitalist (residents or other physicians in the control group), and time spent with hospitalized patients. In addition, we analyzed claims costs and the operating costs for implementing the system within each hospital (Table).

The new set of fee schedules was created specifically for hospitalist care services so hospitals could now claim separate inpatient care fees and hospitalist fees. The standard hospitalist fee schedule is applied only to patients who are on hospitalist-led wards. The fee schedule has two criteria: The hospitalist ward must have 50 beds which are assigned to hospitalists only, and each hospitalist ward has a team of five hospitalists. A maximum of 25 patients could be assigned to an individual hospitalist. However, fees can be adjusted based on individual hospital operation and management after government approval.

Under the national insurance system, the fee schedule is essential to obtain reimbursement for provided services. As a new medical profession, it is important to have the institutional implementation of the hospitalist system. In contrast to those in the United States, inpatients in Korea pay inpatient care fees only, which are charged per day. Therefore, reducing the length of stay without increasing patient volume does not financially benefit the hospital.

The definition of a Korean hospitalist was carefully developed, and a reimbursement system for hospitalists was created within the Korean healthcare system. All hospitalists are medical specialists who have completed advanced education and clinical training in their specialty area (internal medicine or surgery). Creating a definition of a hospitalist and a standard fee schedule was necessary for national incorporation of this new approach. The model must also be accepted by related parties, including healthcare professionals such as hospital executives, nonhospitalist doctors, and nurses. Therefore, the system has a minimum of two requirements to operate at the hospital level, and the remaining factors can be modified by individual hospitals to protect the new discipline within the healthcare system. First, hospitalist services are provided only to hospitalist patients. To establish the new system, limiting the patient range to a specific group was necessary to prevent abuse of human-based resources within the hospital. Second, hospitalists must be stationed near the hospitalist ward to enhance accessibility, patient safety, and healthcare quality. In other words, a hospitalist provides services to hospitalized patients who paid the hospitalist fee, and the hospitalist does not provide care beyond the hospitalist ward (eg, they cannot provide outpatient consultation or provide care on other wards).

Korean national health insurance is the universal health insurance under a single insurer (ie, the government). Therefore, all Korean citizens have national health insurance. Individuals can choose to have additional health insurance (private insurance) if they wish to pay an out-of-pocket fee with their additional private insurance. In Korea, the inpatient care fee includes all fees to provide care for the patient during hospital stays, such as the physician fee, facility fee, and consultation fee. The inpatient care fee schedule is charged per day including all the inpatient care composition. The claim and reimbursement system is different in Korea in that the hospital as a whole submits the claim for reimbursement. There is no separate claim from physicians, lab technicians, or facilities. Doctors provide care to patients and are then paid for the services in terms of salaries. Since the original inpatient care fee schedule was low and insufficient, it was difficult to provide high-quality care. Also, resources for spending on inpatient care management was limited. So a new system to improve inpatient care was needed. Implementing the hospitalist system in Korea led to the creation of a new fee schedule specifically for hospitalists so that hospitals could claim hospitalist fees on top of inpatient care fees when the patient was cared for by the hospitalist. The additional fees in the hospitalist fee schedule allow safe and high-quality care to be provided for patients during hospital stays.

The Korean hospitalist system has been implemented for 3 years with the government’s active involvement, with approximately 250 specialists working as hospitalists as of August 2020. Importantly, Korean hospitalists are not limited to internal medicine specialists; in fact, several different specialties practice as hospitalists, including surgeons and other medical specialists, who account for 20% and 30% of the hospitalist workforce, respectively. Since the system’s implementation, all inpatient care and management is now transferred to specialists from residents in hospitalist wards. This change has increased patient safety and care quality. At the beginning of the pilot study, the concept of a “hospitalist” was new in Korea and the public did not know who a hospitalist was nor what a hospitalist did. However, after 3 years, patients now seek hospitalist care.

National implementation of the hospitalist model represents a key paradigm shift in the Korean healthcare system. The Korean hospitalist system is the result of the hospitals’, doctors’, and patients’ desire for higher-quality care. We expect to see growth of hospitalists in Korea and provision of better, safer, and more efficient inpatient care across specialties, payers, and government. Since we are at the early stage of the system, further efforts to support implementation are required. We hope our implementation process of a new medical system could serve as a model for other countries who are seeking to adopt hospitalist systems within their current healthcare paradigms.

The authors thank the medical professionals, government officers, and other professionals who put great effort into the implementation of the Korean Hospitalist System.

The healthcare system in South Korea (Korea) is evolving. Korea began developing a national health insurance system for the entire population in 1989, and implementation took 12 years. The healthcare insurance premium was set in 1989 when the Korean gross domestic product (GDP) per capita was less than $5,000 USD. Since then, the incremental rise in healthcare insurance premiums, approximately 6% of the typical Korean income, has been relatively small considering the economic growth of Korea.^1-3 The success and rapid adoption of national health insurance in Korea revealed unanticipated problems in three specific areas: low individual contributions relative to costs of care, low levels of reimbursement to providers, and incomplete coverage of medical services, which then require out-of-pocket payments (typically 20% of the inpatient care fee).⁴ Additionally, while little attention has been paid to quality and safety in the past, the nation has come to recognize the importance of these considerations,⁵ particularly with regard to patient expectations for and consumption of medical care and the consequent demand for better services from the medical community and government.⁶

Healthcare constitutes about 7.5% of Korea’s GDP. In contrast, healthcare spending accounts for about 17.7% of US GDP and about 8.8% of the GDP of member nations of the Organisation for Economic Co-operation and Development (OECD) in aggregate. Additionally, Korea has a longer length of hospital stay (16.5 days vs 7.3 days for OECD countries) and fewer practicing physicians (1.1 per 1,000 persons vs 1.9 per 1,000 for OECD countries). Therefore, the average cumulative annual patient hospital days per physician is 2,394 days in Korea, three times higher than that in the OECD countries.⁷ Furthermore, the number of physicians providing hospital care in Korea has remained relatively low.⁸

Despite recent growth in the total number of practicing physicians, the number of hospital-based physicians remains insufficient to cover admitted patients. The pressure for hospital-based physicians to serve large numbers of patients to generate sufficient revenue has deterred growth of more physicians focused on inpatient care.⁶ In order to operate the hospital, doctors must see as many patients as possible because physicians are reimbursed primarily by an inpatient care fee rather than by type or extent of care provided. Therefore, this low fee schedule makes it difficult to provide good quality inpatient care while simultaneously trying to increase accessibility. The costs of testing and treatment are reimbursed through a separate fee schedule.

The Korean government enacted two new policies regarding medical school graduates and residents that led to implementation of a hospitalist system. The first policy created a quota of medical residents to match the total number of medical school graduates.⁹ Before the new regulation, the number of medical resident positions exceeded the number of medical school graduates by 20%, which led to a shortage of resident applicants in “unpopular” medical specialties or departments. These specialties (eg, general surgery, obstetrics and gynecology, urology) have a lower fee schedule, which leads to lower wages while having very high workloads. The decrease in the number of available medical resident positions results in greater workloads for physicians providing inpatient care. These changes, including the shortage of a resident workforce, led to a burgeoning hospital-based attending physician workforce to care for hospitalized patients.

The other policy, created in December 2015 and known as the Act on the Improvement of Training Conditions and Status of Medical Residents, was enacted to improve working conditions for residents by limiting their working hours to 80 or fewer per week.¹⁰ These work-hour restrictions made it nearly impossible to provide 24-hour inpatient care depending solely on residents.^10-12 This policy increased the need for hospitalists in Korea, similar to that of the US Accreditation Council for Graduate Medical Education in 2003, which limited resident work hours. Because of these changes, the hospitalist model was introduced to manage the growing volume of inpatients at teaching hospitals.¹³

The institutional implementation of the Korean hospitalist system was catalyzed by the need to solve current problems such as patient safety, healthcare quality, and residents’ well-being.^8,14 Therefore, the hospitalist system was designed and implemented to meet the needs of patients, medical professionals, and hospitals.^6,8,14 Furthermore, under the universal health insurance system in Korea, institutional implementation also meant creating a new set of fee schedules for hospitalists. The Korean hospitalist system reflects the nuances and challenges faced by the Korean healthcare system.⁵

A council was formed to implement a hospitalist model suitable for Korea. The council was composed of five groups: the Korean Association of Internal Medicine, Korean Surgical Society, Korean Medical Association, Korean Hospital Association, and Korean Academy of Medical Sciences. The Korean Association of Internal Medicine and the Korean Surgical Society were involved in creating a new medical discipline because their members provided a disproportionate amount of inpatient care and were most often responsible for hospital patient safety and quality care. Along with the support of the council, the Ministry of Health and Welfare began to realize the high demand on inpatient care and requested an official proposal to broaden the hospitalist model, with two conditions. First, the government requested a unified proposal from the medical community that reflected the collective voices of individual stakeholders, with an expectation that the new system would focus on patient safety and healthcare quality across all specialties. Second, the proposal had to be detailed and include a specific fee schedule for hospitalist services.

Before implementing a national hospitalist system, we conducted a pilot study supported by funding from the council. This first study, the Korean Hospitalist System Operation and Evaluation Research (September 2015 to August 2016)¹⁴, was designed to (a) determine hospitalist needs (eg, rotation schedule, salary, working conditions) for this new profession, (b) determine the necessary number of hospitalists and appropriate fee schedules to cover salary and benefits, and (c) provide Korean hospitalist models with operational methods to facilitate implementation at individual institutions. The council and research team selected four hospitals for the privately funded pilot study (Table). These hospitals already had an inpatient care system managed by specialists prior to the pilot study, so major changes in patient care and hospital operations were not required.

The pilot study demonstrated improvements in patient satisfaction, medical service quality, and patient safety.^8,14,15 As a result, fees billed from hospitalist services were now covered by national health insurance; previously, they were not covered by any inpatient care fee or bundled service fee. The next study (phase 2) was then conducted to evaluate the national implementation of the hospitalist system and its outcomes. The first phase defined criteria for monitoring and evaluating the institutionalized hospitalist system in Korea. The second phase, initiated in September 2016, evaluated how the implemented system could be expanded nationwide. The government was actively involved in the study; 31 of 344 (9%) general hospitals were selected and able to apply the hospitalist fee schedule for care of patients who were admitted to the hospitalist ward.

To investigate the effect of the hospitalist system, we measured the satisfaction of patients and medical providers (eg, specialists, residents, and nurses). The outcomes were number of doctors’ calls to hospitalists and to other specialties, duration of time required to address medical problems, number of contacts with the hospitalist (residents or other physicians in the control group), and time spent with hospitalized patients. In addition, we analyzed claims costs and the operating costs for implementing the system within each hospital (Table).

The new set of fee schedules was created specifically for hospitalist care services so hospitals could now claim separate inpatient care fees and hospitalist fees. The standard hospitalist fee schedule is applied only to patients who are on hospitalist-led wards. The fee schedule has two criteria: The hospitalist ward must have 50 beds which are assigned to hospitalists only, and each hospitalist ward has a team of five hospitalists. A maximum of 25 patients could be assigned to an individual hospitalist. However, fees can be adjusted based on individual hospital operation and management after government approval.

Under the national insurance system, the fee schedule is essential to obtain reimbursement for provided services. As a new medical profession, it is important to have the institutional implementation of the hospitalist system. In contrast to those in the United States, inpatients in Korea pay inpatient care fees only, which are charged per day. Therefore, reducing the length of stay without increasing patient volume does not financially benefit the hospital.

The definition of a Korean hospitalist was carefully developed, and a reimbursement system for hospitalists was created within the Korean healthcare system. All hospitalists are medical specialists who have completed advanced education and clinical training in their specialty area (internal medicine or surgery). Creating a definition of a hospitalist and a standard fee schedule was necessary for national incorporation of this new approach. The model must also be accepted by related parties, including healthcare professionals such as hospital executives, nonhospitalist doctors, and nurses. Therefore, the system has a minimum of two requirements to operate at the hospital level, and the remaining factors can be modified by individual hospitals to protect the new discipline within the healthcare system. First, hospitalist services are provided only to hospitalist patients. To establish the new system, limiting the patient range to a specific group was necessary to prevent abuse of human-based resources within the hospital. Second, hospitalists must be stationed near the hospitalist ward to enhance accessibility, patient safety, and healthcare quality. In other words, a hospitalist provides services to hospitalized patients who paid the hospitalist fee, and the hospitalist does not provide care beyond the hospitalist ward (eg, they cannot provide outpatient consultation or provide care on other wards).

Korean national health insurance is the universal health insurance under a single insurer (ie, the government). Therefore, all Korean citizens have national health insurance. Individuals can choose to have additional health insurance (private insurance) if they wish to pay an out-of-pocket fee with their additional private insurance. In Korea, the inpatient care fee includes all fees to provide care for the patient during hospital stays, such as the physician fee, facility fee, and consultation fee. The inpatient care fee schedule is charged per day including all the inpatient care composition. The claim and reimbursement system is different in Korea in that the hospital as a whole submits the claim for reimbursement. There is no separate claim from physicians, lab technicians, or facilities. Doctors provide care to patients and are then paid for the services in terms of salaries. Since the original inpatient care fee schedule was low and insufficient, it was difficult to provide high-quality care. Also, resources for spending on inpatient care management was limited. So a new system to improve inpatient care was needed. Implementing the hospitalist system in Korea led to the creation of a new fee schedule specifically for hospitalists so that hospitals could claim hospitalist fees on top of inpatient care fees when the patient was cared for by the hospitalist. The additional fees in the hospitalist fee schedule allow safe and high-quality care to be provided for patients during hospital stays.

The Korean hospitalist system has been implemented for 3 years with the government’s active involvement, with approximately 250 specialists working as hospitalists as of August 2020. Importantly, Korean hospitalists are not limited to internal medicine specialists; in fact, several different specialties practice as hospitalists, including surgeons and other medical specialists, who account for 20% and 30% of the hospitalist workforce, respectively. Since the system’s implementation, all inpatient care and management is now transferred to specialists from residents in hospitalist wards. This change has increased patient safety and care quality. At the beginning of the pilot study, the concept of a “hospitalist” was new in Korea and the public did not know who a hospitalist was nor what a hospitalist did. However, after 3 years, patients now seek hospitalist care.

National implementation of the hospitalist model represents a key paradigm shift in the Korean healthcare system. The Korean hospitalist system is the result of the hospitals’, doctors’, and patients’ desire for higher-quality care. We expect to see growth of hospitalists in Korea and provision of better, safer, and more efficient inpatient care across specialties, payers, and government. Since we are at the early stage of the system, further efforts to support implementation are required. We hope our implementation process of a new medical system could serve as a model for other countries who are seeking to adopt hospitalist systems within their current healthcare paradigms.

The authors thank the medical professionals, government officers, and other professionals who put great effort into the implementation of the Korean Hospitalist System.

Some scientists say they’ve noticed a pattern to the recurring waves of SARS-CoV-2 infections around the globe: As pollen levels increased in outdoor air in 31 countries, COVID-19 cases accelerated.

Photo courtesy Oak Ridge National Laboratory

Yet other recent studies point in the opposite direction, suggesting that peaks in pollen seasons coincide with a fall-off in the spread of some respiratory viruses, like COVID-19 and influenza. There’s even some evidence that pollen may compete with the virus that causes COVID-19 and may even help prevent infection.

So which is it? The answer may still be up in the air.

Doctors don’t fully understand what makes some viruses – like the ones that cause the flu – circulate in seasonal patterns. 

There are, of course, many theories. These revolve around things like temperature and humidity – viruses tend to prefer colder, drier air – something that’s thought to help them spread more easily in the winter months. People are exposed to less sunlight during the winter, as they spend more time indoors, and the earth points away from the sun, providing some natural shielding. That may play a role because ultraviolet light from the sun acts like a natural disinfectant and may help keep circulating viral levels down.

In addition, exposure to sunlight helps the body make vitamin D, which may help keep our immune responses strong. Extreme temperatures – both cold and hot – also change our behavior, so that we spend more time cloistered indoors, where we can more easily cough and sneeze on each other and generally swap more germs.

Spike in pollen, jump in infections

The new study, published in the Proceedings of the National Academy of Sciences, adds a new variable to this mix – pollen. It relies on data from 248 airborne pollen–monitoring sites in 31 countries. The study also took into account other effects, such as population density, temperature, humidity, and lockdown orders. The study authors found that, when pollen in an area spiked, so did infections, after an average lag of about 4 days. The study authors say pollen seemed to account for, on average, 44% of the infection rate variability between countries.

The study authors say pollen could be a culprit in respiratory infections, not because the viruses hitch a ride on pollen grains and travel into our mouth, eyes, and nose, but because pollen seems to perturb our immune defenses, even if a person isn’t allergic to it.

“When we inhale pollen, they end up on our nasal mucosa, and here they diminish the expression of genes that are important for the defense against airborne viruses,” study author Stefanie Gilles, PhD, chair of environmental medicine at the Technical University of Munich, said in a press conference.

In a study published last year, Dr. Gilles found that mice exposed to pollen made less interferon and other protective chemical signals to the immune system. Those then infected with respiratory syncytial virus had more virus in their bodies, compared with mice not exposed to pollen. She seemed to see the same effect in human volunteers.

The study authors think pollen may cause the body to drop its defenses against the airborne virus that causes COVID-19, too.

“If you’re in a crowded room, and other people are there that are asymptomatic, and you’ve just been breathing in pollen all day long, chances are that you’re going to be more susceptible to the virus,” says Lewis Ziska, PhD, a plant physiologist who studies pollen, climate change, and health at Columbia University’s Mailman School of Public Health in New York. “Having a mask is obviously really critical in that regard.”

Masks do a great job of blocking pollen, so wearing one is even more important when pollen and viruses are floating around, he says.

Other researchers, however, say that, while the study raises some interesting questions, it can’t prove that pollen is increasing COVID-19 infections.

“Just because two things happen at the same time doesn’t mean that one causes the other,” says Martijn Hoogeveen, PhD, a professor of technical sciences and environment at the Open University in the Netherlands.

Dr. Hoogeveen’s recent study, published in Science of the Total Environment, found that the arrival of pollen season in the Netherlands coincides with the end of flu season, and that COVID-19 infection peaks tend to follow a similar pattern – exactly the opposite of the PNAS study.

Another preprint study, which focused on the Chicago area, found the same thing – as pollen climbs, flu cases drop. The researchers behind that study think pollen may actually compete with viruses in our airways, helping to block them from infecting our cells.

Patterns may be hard to nail down

Why did these studies reach such different conclusions?

Dr. Hoogeveen’s paper focused on a single country and looked at the incidence of flu infections over four seasons, from 2016 to 2020, while the PNAS study collected data on pollen from January through the first week of April 2020. 

He thinks that a single season, or really part of a season, may not be long enough to see meaningful patterns, especially considering that this new-to-humans virus was spreading quickly at nearly the same time. He says it will be interesting to follow what happens with COVID-19 infections and pollen in the coming months and years.

Dr. Hoogeveen says that in a large study spanning so many countries it would have been nearly impossible to account for differences in pandemic control strategies. Some countries embraced the use of masks, stay-at-home orders, and social distancing, for example, while others took less stringent measures in order to let the virus run its course in pursuit of herd immunity.

Limiting the study area to a single country or city, he says, helps researchers better understand all the variables that might have been in play along with pollen.

“There is no scientific consensus yet, about what it is driving, and that’s what makes it such an interesting field,” he says.

A version of this article first appeared on Medscape.com.

Some scientists say they’ve noticed a pattern to the recurring waves of SARS-CoV-2 infections around the globe: As pollen levels increased in outdoor air in 31 countries, COVID-19 cases accelerated.

Photo courtesy Oak Ridge National Laboratory

Yet other recent studies point in the opposite direction, suggesting that peaks in pollen seasons coincide with a fall-off in the spread of some respiratory viruses, like COVID-19 and influenza. There’s even some evidence that pollen may compete with the virus that causes COVID-19 and may even help prevent infection.

So which is it? The answer may still be up in the air.

Doctors don’t fully understand what makes some viruses – like the ones that cause the flu – circulate in seasonal patterns. 

There are, of course, many theories. These revolve around things like temperature and humidity – viruses tend to prefer colder, drier air – something that’s thought to help them spread more easily in the winter months. People are exposed to less sunlight during the winter, as they spend more time indoors, and the earth points away from the sun, providing some natural shielding. That may play a role because ultraviolet light from the sun acts like a natural disinfectant and may help keep circulating viral levels down.

In addition, exposure to sunlight helps the body make vitamin D, which may help keep our immune responses strong. Extreme temperatures – both cold and hot – also change our behavior, so that we spend more time cloistered indoors, where we can more easily cough and sneeze on each other and generally swap more germs.

Spike in pollen, jump in infections

The new study, published in the Proceedings of the National Academy of Sciences, adds a new variable to this mix – pollen. It relies on data from 248 airborne pollen–monitoring sites in 31 countries. The study also took into account other effects, such as population density, temperature, humidity, and lockdown orders. The study authors found that, when pollen in an area spiked, so did infections, after an average lag of about 4 days. The study authors say pollen seemed to account for, on average, 44% of the infection rate variability between countries.

The study authors say pollen could be a culprit in respiratory infections, not because the viruses hitch a ride on pollen grains and travel into our mouth, eyes, and nose, but because pollen seems to perturb our immune defenses, even if a person isn’t allergic to it.

“When we inhale pollen, they end up on our nasal mucosa, and here they diminish the expression of genes that are important for the defense against airborne viruses,” study author Stefanie Gilles, PhD, chair of environmental medicine at the Technical University of Munich, said in a press conference.

In a study published last year, Dr. Gilles found that mice exposed to pollen made less interferon and other protective chemical signals to the immune system. Those then infected with respiratory syncytial virus had more virus in their bodies, compared with mice not exposed to pollen. She seemed to see the same effect in human volunteers.

The study authors think pollen may cause the body to drop its defenses against the airborne virus that causes COVID-19, too.

“If you’re in a crowded room, and other people are there that are asymptomatic, and you’ve just been breathing in pollen all day long, chances are that you’re going to be more susceptible to the virus,” says Lewis Ziska, PhD, a plant physiologist who studies pollen, climate change, and health at Columbia University’s Mailman School of Public Health in New York. “Having a mask is obviously really critical in that regard.”

Masks do a great job of blocking pollen, so wearing one is even more important when pollen and viruses are floating around, he says.

Other researchers, however, say that, while the study raises some interesting questions, it can’t prove that pollen is increasing COVID-19 infections.

“Just because two things happen at the same time doesn’t mean that one causes the other,” says Martijn Hoogeveen, PhD, a professor of technical sciences and environment at the Open University in the Netherlands.

Dr. Hoogeveen’s recent study, published in Science of the Total Environment, found that the arrival of pollen season in the Netherlands coincides with the end of flu season, and that COVID-19 infection peaks tend to follow a similar pattern – exactly the opposite of the PNAS study.

Another preprint study, which focused on the Chicago area, found the same thing – as pollen climbs, flu cases drop. The researchers behind that study think pollen may actually compete with viruses in our airways, helping to block them from infecting our cells.

Patterns may be hard to nail down

Why did these studies reach such different conclusions?

Dr. Hoogeveen’s paper focused on a single country and looked at the incidence of flu infections over four seasons, from 2016 to 2020, while the PNAS study collected data on pollen from January through the first week of April 2020. 

He thinks that a single season, or really part of a season, may not be long enough to see meaningful patterns, especially considering that this new-to-humans virus was spreading quickly at nearly the same time. He says it will be interesting to follow what happens with COVID-19 infections and pollen in the coming months and years.

Dr. Hoogeveen says that in a large study spanning so many countries it would have been nearly impossible to account for differences in pandemic control strategies. Some countries embraced the use of masks, stay-at-home orders, and social distancing, for example, while others took less stringent measures in order to let the virus run its course in pursuit of herd immunity.

Limiting the study area to a single country or city, he says, helps researchers better understand all the variables that might have been in play along with pollen.

“There is no scientific consensus yet, about what it is driving, and that’s what makes it such an interesting field,” he says.

A version of this article first appeared on Medscape.com.

Some scientists say they’ve noticed a pattern to the recurring waves of SARS-CoV-2 infections around the globe: As pollen levels increased in outdoor air in 31 countries, COVID-19 cases accelerated.

Photo courtesy Oak Ridge National Laboratory

Yet other recent studies point in the opposite direction, suggesting that peaks in pollen seasons coincide with a fall-off in the spread of some respiratory viruses, like COVID-19 and influenza. There’s even some evidence that pollen may compete with the virus that causes COVID-19 and may even help prevent infection.

So which is it? The answer may still be up in the air.

Doctors don’t fully understand what makes some viruses – like the ones that cause the flu – circulate in seasonal patterns. 

There are, of course, many theories. These revolve around things like temperature and humidity – viruses tend to prefer colder, drier air – something that’s thought to help them spread more easily in the winter months. People are exposed to less sunlight during the winter, as they spend more time indoors, and the earth points away from the sun, providing some natural shielding. That may play a role because ultraviolet light from the sun acts like a natural disinfectant and may help keep circulating viral levels down.

In addition, exposure to sunlight helps the body make vitamin D, which may help keep our immune responses strong. Extreme temperatures – both cold and hot – also change our behavior, so that we spend more time cloistered indoors, where we can more easily cough and sneeze on each other and generally swap more germs.

Spike in pollen, jump in infections

The new study, published in the Proceedings of the National Academy of Sciences, adds a new variable to this mix – pollen. It relies on data from 248 airborne pollen–monitoring sites in 31 countries. The study also took into account other effects, such as population density, temperature, humidity, and lockdown orders. The study authors found that, when pollen in an area spiked, so did infections, after an average lag of about 4 days. The study authors say pollen seemed to account for, on average, 44% of the infection rate variability between countries.

The study authors say pollen could be a culprit in respiratory infections, not because the viruses hitch a ride on pollen grains and travel into our mouth, eyes, and nose, but because pollen seems to perturb our immune defenses, even if a person isn’t allergic to it.

“When we inhale pollen, they end up on our nasal mucosa, and here they diminish the expression of genes that are important for the defense against airborne viruses,” study author Stefanie Gilles, PhD, chair of environmental medicine at the Technical University of Munich, said in a press conference.

In a study published last year, Dr. Gilles found that mice exposed to pollen made less interferon and other protective chemical signals to the immune system. Those then infected with respiratory syncytial virus had more virus in their bodies, compared with mice not exposed to pollen. She seemed to see the same effect in human volunteers.

The study authors think pollen may cause the body to drop its defenses against the airborne virus that causes COVID-19, too.

“If you’re in a crowded room, and other people are there that are asymptomatic, and you’ve just been breathing in pollen all day long, chances are that you’re going to be more susceptible to the virus,” says Lewis Ziska, PhD, a plant physiologist who studies pollen, climate change, and health at Columbia University’s Mailman School of Public Health in New York. “Having a mask is obviously really critical in that regard.”

Masks do a great job of blocking pollen, so wearing one is even more important when pollen and viruses are floating around, he says.

Other researchers, however, say that, while the study raises some interesting questions, it can’t prove that pollen is increasing COVID-19 infections.

“Just because two things happen at the same time doesn’t mean that one causes the other,” says Martijn Hoogeveen, PhD, a professor of technical sciences and environment at the Open University in the Netherlands.

Dr. Hoogeveen’s recent study, published in Science of the Total Environment, found that the arrival of pollen season in the Netherlands coincides with the end of flu season, and that COVID-19 infection peaks tend to follow a similar pattern – exactly the opposite of the PNAS study.

Another preprint study, which focused on the Chicago area, found the same thing – as pollen climbs, flu cases drop. The researchers behind that study think pollen may actually compete with viruses in our airways, helping to block them from infecting our cells.

Patterns may be hard to nail down

Why did these studies reach such different conclusions?

Dr. Hoogeveen’s paper focused on a single country and looked at the incidence of flu infections over four seasons, from 2016 to 2020, while the PNAS study collected data on pollen from January through the first week of April 2020. 

He thinks that a single season, or really part of a season, may not be long enough to see meaningful patterns, especially considering that this new-to-humans virus was spreading quickly at nearly the same time. He says it will be interesting to follow what happens with COVID-19 infections and pollen in the coming months and years.

Dr. Hoogeveen says that in a large study spanning so many countries it would have been nearly impossible to account for differences in pandemic control strategies. Some countries embraced the use of masks, stay-at-home orders, and social distancing, for example, while others took less stringent measures in order to let the virus run its course in pursuit of herd immunity.

Limiting the study area to a single country or city, he says, helps researchers better understand all the variables that might have been in play along with pollen.

“There is no scientific consensus yet, about what it is driving, and that’s what makes it such an interesting field,” he says.

A version of this article first appeared on Medscape.com.

Medicare payments for branded neurologic drugs jumped 50% over a 5-year period, while claims for these medications increased by just 8%, new research shows. Results of the retrospective study also showed that most of the increased costs for these agents were due to rising costs for neuroimmunology drugs, mainly for those used to treat multiple sclerosis (MS).

“The same brand name medication in 2017 cost approximately 50% more than in 2013,” said Adam de Havenon, MD, assistant professor of neurology, University of Utah, Salt Lake City.

“An analogy would be if you bought an iPhone 5 in 2013 for $500, and then in 2017, you were asked to pay $750 for the exact same iPhone 5,” Dr. de Havenon added.

The study findings were published online March 10 in the journal Neurology.
 

$26 billion in payments

Both neurologists and patients are concerned about the high cost of prescription drugs for neurologic diseases, and Medicare Part D data indicate that these drugs are the most expensive component of neurologic care, the researchers noted. In addition, out-of-pocket costs have increased significantly for patients with neurologic disease such as Parkinson’s disease, epilepsy, and MS.

To understand trends in payments for neurologic drugs, Dr. de Havenon and colleagues analyzed Medicare Part D claims filed from 2013 to 2017. The payments include costs paid by Medicare, the patient, government subsidies, and other third-party payers.

In addition to examining more current Medicare Part D data than previous studies, the current analysis examined all medications prescribed by neurologists that consistently remained branded or generic during the 5-year study period, said Dr. de Havenon. This approach resulted in a large number of claims and a large total cost.

To calculate the percentage change in annual payment claims, the researchers used 2013 prices as a reference point. They identified drugs named in 2013 claims and classified them as generic, brand-name only, or brand-name with generic equivalent. Researchers also divided the drugs by neurologic subspecialty.

The analysis included 520 drugs, all of which were available in each year of the study period. Of these drugs, 322 were generic, 61 were brand-name only, and 137 were brand-name with a generic equivalent. There were 90.7 million total claims.

Results showed total payments amounted to $26.65 billion. Yearly total payments increased from $4.05 billion in 2013 to $6.09 billion in 2017, representing a 50.4% increase, even after adjusting for inflation. Total claims increased by 7.6% – from 17.1 million in 2013 to 18.4 million in 2017.

From 2013 to 2017, claim payments increased by 0.6% for generic drugs, 42.4% for brand-name only drugs, and 45% for brand-name drugs with generic equivalents. The proportion of claims increased from 81.9% to 88% for generic drugs and from 4.9% to 6.2% for brand-name only drugs.

However, the proportion of claims for brand-name drugs with generic equivalents decreased from 13.3% to 5.8%.
 

Treatment barrier

Neuroimmunologic drugs, most of which were prescribed for MS, had exceptional cost, the researchers noted. These drugs accounted for more than 50% of payments but only 4.3% of claims. Claim payment for these drugs increased by 46.9% during the study period, from $3,337 to $4,902.

When neuroimmunologic drugs were removed from the analysis there was still significant increase in claim payments for brand-name only drugs (50.4%) and brand-name drugs with generic equivalents (45.6%).

Although neuroimmunologic medicines, including monoclonal antibodies, are more expensive to produce, this factor alone does not explain their exceptional cost, said Dr. de Havenon. “The high cost of brand-name drugs in this speciality is likely because the market bears it,” he added. “In other words, MS is a disabling disease and the medications work, so historically the Centers for Medicare & Medicaid Services have been willing to tolerate the high cost of these primarily brand-name medications.”

Several countries have controlled drug costs by negotiating with pharmaceutical companies and through legislation, Dr. de Havenon noted.

“My intent with this article was to raise awareness on the topic, which I struggle with frequently as a clinician. I know I want my patients to have a medication, but the cost prevents it,” he said.
 

‘Unfettered’ price-setting

Commenting on the findings, Robert J. Fox, MD, vice chair for research at the Neurological Institute of the Cleveland Clinic, said the study “brings into clear light” what neurologists, particularly those who treat MS, have long suspected but did not really know. These neurologists “are typically distanced from the payment aspects of the medications they prescribe,” said Dr. Fox, who was not involved with the research.

Although a particular strength of the study was its comprehensiveness, the researchers excluded infusion claims – which account for a large portion of total patient care costs for many disorders, he noted.

Drugs for MS historically have been expensive, ostensibly because of their high cost of development. In addition, the large and continued price increase that occurs long after these drugs have been approved remains unexplained, said Dr. Fox.

He noted that the study findings might not directly affect clinical practice because neurologists will continue prescribing medications they think are best for their patients. “Instead, I think this is a lesson to lawmakers about the massive error in the Medicare Modernization Act of 2003, where the federal government was prohibited from negotiating drug prices. If the seller is unfettered in setting a price, then no one should be surprised when the price rises,” Dr. Fox said.

Because many new drugs and new generic formulations for treating MS have become available during the past year, “repeating these types of economic studies for the period 2020-2025 will help us understand if generic competition – as well as new laws if they are passed – alter price,” he concluded.

The study was funded by the American Academy of Neurology, which publishes Neurology. Dr. de Havenon has received clinical research funding from AMAG Pharmaceuticals and Regeneron Pharmaceuticals. Dr. Fox receives consulting fees from many pharmaceutical companies involved in the development of therapies for MS.

A version of this article first appeared on Medscape.com.

Medicare payments for branded neurologic drugs jumped 50% over a 5-year period, while claims for these medications increased by just 8%, new research shows. Results of the retrospective study also showed that most of the increased costs for these agents were due to rising costs for neuroimmunology drugs, mainly for those used to treat multiple sclerosis (MS).

“The same brand name medication in 2017 cost approximately 50% more than in 2013,” said Adam de Havenon, MD, assistant professor of neurology, University of Utah, Salt Lake City.

“An analogy would be if you bought an iPhone 5 in 2013 for $500, and then in 2017, you were asked to pay $750 for the exact same iPhone 5,” Dr. de Havenon added.

The study findings were published online March 10 in the journal Neurology.
 

$26 billion in payments

Both neurologists and patients are concerned about the high cost of prescription drugs for neurologic diseases, and Medicare Part D data indicate that these drugs are the most expensive component of neurologic care, the researchers noted. In addition, out-of-pocket costs have increased significantly for patients with neurologic disease such as Parkinson’s disease, epilepsy, and MS.

To understand trends in payments for neurologic drugs, Dr. de Havenon and colleagues analyzed Medicare Part D claims filed from 2013 to 2017. The payments include costs paid by Medicare, the patient, government subsidies, and other third-party payers.

In addition to examining more current Medicare Part D data than previous studies, the current analysis examined all medications prescribed by neurologists that consistently remained branded or generic during the 5-year study period, said Dr. de Havenon. This approach resulted in a large number of claims and a large total cost.

To calculate the percentage change in annual payment claims, the researchers used 2013 prices as a reference point. They identified drugs named in 2013 claims and classified them as generic, brand-name only, or brand-name with generic equivalent. Researchers also divided the drugs by neurologic subspecialty.

The analysis included 520 drugs, all of which were available in each year of the study period. Of these drugs, 322 were generic, 61 were brand-name only, and 137 were brand-name with a generic equivalent. There were 90.7 million total claims.

Results showed total payments amounted to $26.65 billion. Yearly total payments increased from $4.05 billion in 2013 to $6.09 billion in 2017, representing a 50.4% increase, even after adjusting for inflation. Total claims increased by 7.6% – from 17.1 million in 2013 to 18.4 million in 2017.

From 2013 to 2017, claim payments increased by 0.6% for generic drugs, 42.4% for brand-name only drugs, and 45% for brand-name drugs with generic equivalents. The proportion of claims increased from 81.9% to 88% for generic drugs and from 4.9% to 6.2% for brand-name only drugs.

However, the proportion of claims for brand-name drugs with generic equivalents decreased from 13.3% to 5.8%.
 

Treatment barrier

Neuroimmunologic drugs, most of which were prescribed for MS, had exceptional cost, the researchers noted. These drugs accounted for more than 50% of payments but only 4.3% of claims. Claim payment for these drugs increased by 46.9% during the study period, from $3,337 to $4,902.

When neuroimmunologic drugs were removed from the analysis there was still significant increase in claim payments for brand-name only drugs (50.4%) and brand-name drugs with generic equivalents (45.6%).

Although neuroimmunologic medicines, including monoclonal antibodies, are more expensive to produce, this factor alone does not explain their exceptional cost, said Dr. de Havenon. “The high cost of brand-name drugs in this speciality is likely because the market bears it,” he added. “In other words, MS is a disabling disease and the medications work, so historically the Centers for Medicare & Medicaid Services have been willing to tolerate the high cost of these primarily brand-name medications.”

Several countries have controlled drug costs by negotiating with pharmaceutical companies and through legislation, Dr. de Havenon noted.

“My intent with this article was to raise awareness on the topic, which I struggle with frequently as a clinician. I know I want my patients to have a medication, but the cost prevents it,” he said.
 

‘Unfettered’ price-setting

Commenting on the findings, Robert J. Fox, MD, vice chair for research at the Neurological Institute of the Cleveland Clinic, said the study “brings into clear light” what neurologists, particularly those who treat MS, have long suspected but did not really know. These neurologists “are typically distanced from the payment aspects of the medications they prescribe,” said Dr. Fox, who was not involved with the research.

Although a particular strength of the study was its comprehensiveness, the researchers excluded infusion claims – which account for a large portion of total patient care costs for many disorders, he noted.

Drugs for MS historically have been expensive, ostensibly because of their high cost of development. In addition, the large and continued price increase that occurs long after these drugs have been approved remains unexplained, said Dr. Fox.

He noted that the study findings might not directly affect clinical practice because neurologists will continue prescribing medications they think are best for their patients. “Instead, I think this is a lesson to lawmakers about the massive error in the Medicare Modernization Act of 2003, where the federal government was prohibited from negotiating drug prices. If the seller is unfettered in setting a price, then no one should be surprised when the price rises,” Dr. Fox said.

Because many new drugs and new generic formulations for treating MS have become available during the past year, “repeating these types of economic studies for the period 2020-2025 will help us understand if generic competition – as well as new laws if they are passed – alter price,” he concluded.

The study was funded by the American Academy of Neurology, which publishes Neurology. Dr. de Havenon has received clinical research funding from AMAG Pharmaceuticals and Regeneron Pharmaceuticals. Dr. Fox receives consulting fees from many pharmaceutical companies involved in the development of therapies for MS.

A version of this article first appeared on Medscape.com.

Medicare payments for branded neurologic drugs jumped 50% over a 5-year period, while claims for these medications increased by just 8%, new research shows. Results of the retrospective study also showed that most of the increased costs for these agents were due to rising costs for neuroimmunology drugs, mainly for those used to treat multiple sclerosis (MS).

“The same brand name medication in 2017 cost approximately 50% more than in 2013,” said Adam de Havenon, MD, assistant professor of neurology, University of Utah, Salt Lake City.

“An analogy would be if you bought an iPhone 5 in 2013 for $500, and then in 2017, you were asked to pay $750 for the exact same iPhone 5,” Dr. de Havenon added.

The study findings were published online March 10 in the journal Neurology.
 

$26 billion in payments

Both neurologists and patients are concerned about the high cost of prescription drugs for neurologic diseases, and Medicare Part D data indicate that these drugs are the most expensive component of neurologic care, the researchers noted. In addition, out-of-pocket costs have increased significantly for patients with neurologic disease such as Parkinson’s disease, epilepsy, and MS.

To understand trends in payments for neurologic drugs, Dr. de Havenon and colleagues analyzed Medicare Part D claims filed from 2013 to 2017. The payments include costs paid by Medicare, the patient, government subsidies, and other third-party payers.

In addition to examining more current Medicare Part D data than previous studies, the current analysis examined all medications prescribed by neurologists that consistently remained branded or generic during the 5-year study period, said Dr. de Havenon. This approach resulted in a large number of claims and a large total cost.

To calculate the percentage change in annual payment claims, the researchers used 2013 prices as a reference point. They identified drugs named in 2013 claims and classified them as generic, brand-name only, or brand-name with generic equivalent. Researchers also divided the drugs by neurologic subspecialty.

The analysis included 520 drugs, all of which were available in each year of the study period. Of these drugs, 322 were generic, 61 were brand-name only, and 137 were brand-name with a generic equivalent. There were 90.7 million total claims.

Results showed total payments amounted to $26.65 billion. Yearly total payments increased from $4.05 billion in 2013 to $6.09 billion in 2017, representing a 50.4% increase, even after adjusting for inflation. Total claims increased by 7.6% – from 17.1 million in 2013 to 18.4 million in 2017.

From 2013 to 2017, claim payments increased by 0.6% for generic drugs, 42.4% for brand-name only drugs, and 45% for brand-name drugs with generic equivalents. The proportion of claims increased from 81.9% to 88% for generic drugs and from 4.9% to 6.2% for brand-name only drugs.

However, the proportion of claims for brand-name drugs with generic equivalents decreased from 13.3% to 5.8%.
 

Treatment barrier

Neuroimmunologic drugs, most of which were prescribed for MS, had exceptional cost, the researchers noted. These drugs accounted for more than 50% of payments but only 4.3% of claims. Claim payment for these drugs increased by 46.9% during the study period, from $3,337 to $4,902.

When neuroimmunologic drugs were removed from the analysis there was still significant increase in claim payments for brand-name only drugs (50.4%) and brand-name drugs with generic equivalents (45.6%).

Although neuroimmunologic medicines, including monoclonal antibodies, are more expensive to produce, this factor alone does not explain their exceptional cost, said Dr. de Havenon. “The high cost of brand-name drugs in this speciality is likely because the market bears it,” he added. “In other words, MS is a disabling disease and the medications work, so historically the Centers for Medicare & Medicaid Services have been willing to tolerate the high cost of these primarily brand-name medications.”

Several countries have controlled drug costs by negotiating with pharmaceutical companies and through legislation, Dr. de Havenon noted.

“My intent with this article was to raise awareness on the topic, which I struggle with frequently as a clinician. I know I want my patients to have a medication, but the cost prevents it,” he said.
 

‘Unfettered’ price-setting

Commenting on the findings, Robert J. Fox, MD, vice chair for research at the Neurological Institute of the Cleveland Clinic, said the study “brings into clear light” what neurologists, particularly those who treat MS, have long suspected but did not really know. These neurologists “are typically distanced from the payment aspects of the medications they prescribe,” said Dr. Fox, who was not involved with the research.

Although a particular strength of the study was its comprehensiveness, the researchers excluded infusion claims – which account for a large portion of total patient care costs for many disorders, he noted.

Drugs for MS historically have been expensive, ostensibly because of their high cost of development. In addition, the large and continued price increase that occurs long after these drugs have been approved remains unexplained, said Dr. Fox.

He noted that the study findings might not directly affect clinical practice because neurologists will continue prescribing medications they think are best for their patients. “Instead, I think this is a lesson to lawmakers about the massive error in the Medicare Modernization Act of 2003, where the federal government was prohibited from negotiating drug prices. If the seller is unfettered in setting a price, then no one should be surprised when the price rises,” Dr. Fox said.

Because many new drugs and new generic formulations for treating MS have become available during the past year, “repeating these types of economic studies for the period 2020-2025 will help us understand if generic competition – as well as new laws if they are passed – alter price,” he concluded.

The study was funded by the American Academy of Neurology, which publishes Neurology. Dr. de Havenon has received clinical research funding from AMAG Pharmaceuticals and Regeneron Pharmaceuticals. Dr. Fox receives consulting fees from many pharmaceutical companies involved in the development of therapies for MS.

A version of this article first appeared on Medscape.com.

The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The American Academy of Pediatrics recently issued five recommendations for the most common dermatologic problems in primary care pediatrics.

Topics include diagnostic and management strategies for a variety of conditions, including atopic dermatitis, fungal infections, and autoimmune conditions.

The AAP Section on Dermatology created the recommendations, which were then reviewed and approved by “more than a dozen relevant AAP committees, councils, and sections,” before final approval by the AAP executive committee and board of directors.

The final list represents a collaborative effort with the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, which aims “to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, [and] truly necessary.”

Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, said that the recommendations are “a fine set of suggestions to help health care providers with some of their pediatric dermatology issues.”

• To begin, the AAP recommended against use of combination topical steroid antifungals for candida skin infections, diaper dermatitis, and tinea corporis, despite approvals for these indications.

“Many providers are unaware that the combination products contain a relatively high-potency topical steroid,” the AAP wrote, noting that “combination products are also often expensive and not covered by pharmacy plans.”

Diaper dermatitis responds best to barrier creams and ointments alone, according to the AAP. If needed, a topical, low-potency steroid may be used no more than twice a day, and tapered with improvement. Similarly, the AAP recommended a separate, low-potency steroid for tinea corporis if pruritus is severe.

• In contrast with this call for minimal treatment intensity, the AAP recommended a more intensive approach to tinea capitis, advising against topical medications alone.

“Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection,” the AAP wrote. “This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.”

While medicated shampoos may still be used as adjunctive treatments for tinea capitis, the AAP recommended primary therapy with either griseofulvin or terbinafine, slightly favoring terbinafine because of adequate efficacy, lesser expense, and shorter regimen.

According to Dr. Eichenfield, a more thorough workup should also be considered.

“Consider culturing possible tinea capitis, so that oral antifungals can be used judiciously and not used for other scaling scalp diagnoses,” he said.

• For most cases of atopic dermatitis, the AAP advised against oral or injected corticosteroids, despite rapid efficacy, because of potential for adverse events, such as adrenal suppression, growth retardation, and disease worsening upon discontinuation. Instead, they recommended topical therapies, “good skin care practices,” and if necessary, “phototherapy and/or steroid-sparing systemic agents.”

“Systemic corticosteroids should only be prescribed for severe flares once all other treatment options have been exhausted and should be limited to a short course for the purpose of bridging to a steroid-sparing agent,” the AAP wrote.

Dr. Eichenfield emphasized this point, noting that new therapies have expanded treatment options.

“Be aware of the advances in atopic dermatitis,” he said, “with newer topical medications and with a new systemic biologic agent approved for moderate to severe refractory atopic dermatitis for ages 6 and older.”

• Turning to diagnostic strategies, the AAP recommended against routine laboratory testing for associated autoimmune diseases among patients with vitiligo, unless clinical signs and/or symptoms of such diseases are present.

“There is no convincing evidence that extensive workups in the absence of specific clinical suspicion improves outcomes for patients and may in fact beget additional costs and harms,” the AAP wrote. “Although many studies suggest ordering these tests, it is based largely on the increased cosegregation of vitiligo and thyroid disease and not on improved outcomes from having identified an abnormal laboratory test result.”

• Similarly, the AAP advised practitioners to avoid routinely testing patients with alopecia areata for other diseases if relevant symptoms and signs aren’t present.

“As in the case of vitiligo, it is more common to find thyroid autoantibodies or subclinical hypothyroidism than overt thyroid disease, unless there are clinically suspicious findings,” the AAP wrote. “Patients identified as having subclinical hypothyroidism are not currently treated and may even have resolution of the abnormal TSH.”

Before drawing blood, Dr. Eichenfield suggested that clinicians first ask the right questions.

“Be comfortable with screening questions about growth, weight, or activity changes to assist with decisions for thyroid screening in a patient with vitiligo or alopecia areata,” he said.

Choosing Wisely is an initiative of the American Board of Internal Medicine. The AAP and Dr. Eichenfield reported no conflicts of interest.

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

The COVID-19 pandemic catalyzed the transformation of Internet-based, remotely accessible innovative technologies. Internet-based customer service delivery technology was rapidly adopted and utilized by several services industries, but health care systems in most of the countries across the world faced unique challenges in adopting the technology for the delivery of health care services. The health care ecosystem of the United States was not immune to such challenges, and several significant barriers surfaced while the pandemic was underway.

Complexly structured, fragmented, unprepared, and overly burnt-out health systems in the United States arguably have fallen short of maximizing the value of telehealth in delivering safe, easily accessible, comprehensive, and cost-effective health care services. In this essay, we examine the reasons for such a suboptimal performance and discuss a few important strategies that may be useful in maximizing the value of telehealth value in several, appropriate health care services.
 

Hospitals and telehealth

Are hospitalists preparing ourselves “not to see” patients in a hospital-based health care delivery setting? If you have not yet started yet, now may be the right time! Yes, a certain percentage of doctor-patient encounters in hospital settings will remain virtual forever.

A well-established telehealth infrastructure is rarely found in most U.S. hospitals, although the COVID-19 pandemic has unexpectedly boosted the rapid growth of telehealth in the country.¹ Public health emergency declarations in the United States in the face of the COVID-19 crisis have facilitated two important initiatives to restore health care delivery amidst formal and informal lockdowns that brought states to a grinding halt. These extend from expansion of virtual services, including telehealth, virtual check-ins, and e-visits, to the decision by the Department of Health & Human Services Office of Civil Rights to exercise enforcement discretion and waive penalties for the use of relatively inexpensive, non–public-facing mobile and other audiovisual technology tools.²

Hospital-based care in the United States taps nearly 33% of national health expenditure. An additional 30% of national health expenditure that is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered at health care facilities.³ Studies show that about 20% of ED visits could potentially be avoided via virtual urgent care offerings.⁴ A rapidly changing health care ecosystem is proving formidable for most hospital systems, and a test for their resilience and agility. Not just the implementation of telehealth is challenging, but getting it right is the key success factor.
 

Hospital-based telehealth

Expansion of telehealth coverage by the Centers for Medicare & Medicaid Services and most commercial payers did not quite ride the pandemic-induced momentum across the care continuum. Hospitals are lagging far behind ambulatory care in implementing telehealth. As illustrated in the “4-T Matrix” (see graphic) we would like to examine four key reasons for such a sluggish initial uptake and try to propose four important strategies that may help us to maximize the value created by telehealth technologies.

1. Timing

The health care system has always lagged far behind other service industries in terms of technology adaptation. Because of the unique nature of health care services, face-to-face interaction supersedes all other forms of communication. A rapidly evolving pandemic was not matched by simultaneous technology education for patients and providers. The enormous choice of hard-to-navigate telehealth tools; time and labor-intensive implementation; and uncertainty around payer, policy, and regulatory expectations might have precluded providers from the rapid adoption of telehealth in the hospital setting. Patients’ specific characteristics, such as the absence of technology-centered education, information, age, comorbidities, lack of technical literacy, and dependency on caregivers contributed to the suboptimal response from patients and families.

Deploying simple, ubiquitous, user-friendly, and technologically less challenging telehealth solutions may be a better approach to increase the adoption of such solutions by providers and patients. Hospitals need to develop and distribute telehealth user guides in all possible modes of communication. Provider-centric in-service sessions, workshops, and live support by “superuser teams” often work well in reducing end-user resistance.

2. Technical

Current electronic medical records vary widely in their features and offerings, and their ability to interact with third-party software and platforms. Dissatisfaction of end users with EMRs is well known, as is their likely relationship to burnout. Recent research continues to show a strong relationship between EMR usability and the odds of burnout among physicians.⁵ In the current climate, administrators and health informaticists have the responsibility to avoid adding increased burdens to end users.

Another issue is the limited connectivity in many remote/rural areas that would impact implementation of telehealth platforms. Studies indicate that 33% of rural Americans lack access to high-speed broadband Internet to support video visits.⁶ The recent successful implementation of telehealth across 530 providers in 75 ambulatory practices operated by Munson Healthcare, a rural health system in northern Michigan, sheds light on the technology’s enormous potential in providing safe access to rural populations.^6,7

Privacy and safety of patient data is of paramount importance. According to a national poll on healthy aging by the University of Michigan in May 2019, targeting older adults, 47% of survey responders expressed difficulty using technology and 49% of survey responders were concerned about privacy.⁸ Use of certification and other tools offered by the Office of the National Coordinator for Health Information Technology would help reassure users, and the ability to capture and share images between providers would be of immense benefit in facilitating e-consults.

The need of the hour is redesigned work flow, to help providers adopt and use virtual care/telehealth efficiently. Work flow redesign must be coupled with technological advances to allow seamless integration of third-party telehealth platforms into existing EMR systems or built directly into EMRs. Use of quality metrics and analytical tools specific to telehealth would help measure the technology’s impact on patient care, outcomes, and end-user/provider experience.

3. Teams and training

Outcomes of health care interventions are often determined by the effectiveness of teams. Irrespective of how robust health care systems may have been initially, rapidly spreading infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and patients to a breaking point.⁵ Decentralized, uncoordinated, and siloed efforts by individual teams across the care continuum were contributing factors for the partial success of telehealth care delivery pathways. The hospital systems with telehealth-ready teams at the start of the COVID-19 pandemic were so rare that the knowledge and technical training opportunities for innovators grew severalfold during the pandemic.

As per the American Medical Association, telehealth success is massively dependent on building the right team. Core, leadership, advisory, and implementation teams comprised of clinical representatives, end users, administrative personnel, executive members of the organization, technical experts, and payment/policy experts should be put together before implementing a telehealth strategy.⁹ Seamless integration of hospital-based care with ambulatory care via a telehealth platform is only complete when care managers are trained and deployed to fulfill the needs of a diverse group of patients. Deriving overall value from telehealth is only possible when there is a skill development, training and mentoring team put in place.

4. Thinking

In most U.S. hospitals, inpatient health care is equally distributed between nonprocedure and procedure-based services. Hospitals resorted to suspension of nonemergent procedures to mitigate the risk of spreading COVID-19. This was further compounded by many patients’ self-selection to defer care, an abrupt reduction in the influx of patients from the referral base because of suboptimally operating ambulatory care services, leading to low hospital occupancy.

Hospitals across the nation have gone through a massive short-term financial crunch and unfavorable cash-flow forecast, which prompted a paradoxical work-force reduction. While some argue that it may be akin to strategic myopia, the authors believed that such a response is strategically imperative to keep the hospital afloat. It is reasonable to attribute the paucity of innovation to constrained resources, and health systems are simply staying overly optimistic about “weathering the storm” and reverting soon to “business as usual.” The technological framework necessary for deploying a telehealth solution often comes with a price. Financially challenged hospital systems rarely exercise any capital-intensive activities. By contrast, telehealth adoption by ambulatory care can result in quicker resumption of patient care in community settings. A lack of operational and infrastructure synchrony between ambulatory and in-hospital systems has failed to capture telehealth-driven inpatient volume. For example, direct admissions from ambulatory telehealth referrals was a missed opportunity in several places. Referrals for labs, diagnostic tests, and other allied services could have helped hospitals offset their fixed costs. Similarly, work flows related to discharge and postdischarge follow up rarely embrace telehealth tools or telehealth care pathways. A brisk change in the health care ecosystem is partly responsible for this.

Digital strategy needs to be incorporated into business strategy. For the reasons already discussed, telehealth technology is not a “nice to have” anymore, but a “must have.” At present, providers are of the opinion that about 20% of their patient services can be delivered via a telehealth platform. Similar trends are observed among patients, as a new modality of access to care is increasingly beneficial to them. Telehealth must be incorporated in standardized hospital work flows. Use of telehealth for preoperative clearance will greatly minimize same-day surgery cancellations. Given the potential shortage in resources, telehealth adoption for inpatient consultations will help systems conserve personal protective equipment, minimize the risk of staff exposure to COVID-19, and improve efficiency.

Digital strategy also prompts the reengineering of care delivery.¹⁰ Excessive and unused physical capacity can be converted into digital care hubs. Health maintenance, prevention, health promotion, health education, and chronic disease management not only can serve a variety of patient groups but can also help address the “last-mile problem” in health care. A successful digital strategy usually has three important components – Commitment: Hospital leadership is committed to include digital transformation as a strategic objective; Cost: Digital strategy is added as a line item in the budget; and Control: Measurable metrics are put in place to monitor the performance, impact, and influence of the digital strategy.
 

Conclusion

For decades, most U.S. health systems occupied the periphery of technological transformation when compared to the rest of the service industry. While most health systems took a heroic approach to the adoption of telehealth during COVID-19, despite being unprepared, the need for a systematic telehealth deployment is far from being adequately fulfilled. The COVID-19 pandemic brought permanent changes to several business disciplines globally. Given the impact of the pandemic on the health and overall wellbeing of American society, the U.S. health care industry must leave no stone unturned in its quest for transformation.

Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark, and is cofounder/president of SHM’s Arkansas chapter. Dr. Prasad is medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He is cochair of SHM’s IT Special Interest Group, sits on the HQPS committee, and is president of SHM’s Wisconsin chapter. Dr. Palabindala is the medical director, utilization management, and physician advisory services at the University of Mississippi Medical Center and an associate professor of medicine and academic hospitalist at the University of Mississippi, both in Jackson.

References

1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” Computerworld. 2020 Apr 27. www.computerworld.com/article/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care-is-here-to-stay.html. Accessed 2020 Sep 12.

2. Department of Health & Human Services. “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed 2020 Sep 12.

3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed 2020 Sep 12.

4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” McKinsey & Company. 2020 May 29. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12.

5. Melnick ER et al. The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among U.S. Physicians. Mayo Clin Proc. 2020 March;95(3):476-87.

6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med Inform Assoc. 2020 Nov;27(11):1816-8. .

7. American Academy of Family Physicians. “Study Examines Telehealth, Rural Disparities in Pandemic.” 2020 July 30. www.aafp.org/news/practice-professional-issues/20200730ruraltelehealth.html. Accessed 2020 Dec 15.

8. Kurlander J et al. “Virtual Visits: Telehealth and Older Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle.net/2027.42/151376.

9. American Medical Association. Telehealth Implementation Playbook. 2019. www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf.

10. Smith AC et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-13.
 

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

A version of this article first appeared on Medscape.com.

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

A version of this article first appeared on Medscape.com.

Anthony Fauci, MD, says he’s concerned about how Americans will react once the coronavirus pandemic is brought under control, CBS News reports.

Courtesy American College of Chest Physicians

Noting that an American Psychological Association survey showed people reporting high stress levels because of the pandemic, CBS’s Norah O’Donnell asked if Dr. Fauci was concerned about a possible “mental health pandemic.”

“Very much so,” Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases and a top White House coronavirus adviser, replied.

“That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted,” Dr. Fauci said.

Some of the problems could include prolonged physical symptoms and the economic effects of the pandemic, he said.

“And then the other things: Not only the mental health effects, but many people have put off routine types of medical examinations that they normally would have done,” Dr. Fauci said.

“I hope we don’t see an increase in some preventable situations that would not have happened if people had the normal access to medical care, which clearly was interrupted by the shutdown associated with COVID-19,” he added.

The American Psychological Association released the survey results March 11 in what many people consider the 1-year anniversary of the start of the coronavirus pandemic.

“The prolonged stress experienced by adults, especially the high levels of stress reported by Americans directly linked to the pandemic, is seriously affecting mental and physical health, including changes to weight, sleep and alcohol use,” the APA said in a news release.

Some of the key findings of the survey include:
 

• 61% of respondents reported experiencing undesired weight changes since the start of the pandemic.
• 67% said their sleep habits changed, with 35% saying they slept more and 31% less.
• 23% reported drinking more alcohol to cope with stress.
• 47% said they delayed or canceled health care services because of the pandemic.
• 48% said their stress levels had increased.

A version of this article first appeared on Medscape.com.