Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

My hospitalist group, which has nine employees, is hospital-employed in a small Midwest town. We use the traditional seven-on and seven-off rotation and hire locum tenens to fill schedule gaps, as we have a couple of MDs who recently left the group. A few of us are concerned because our “boss,” who controls the schedule, does not put himself in rotation regularly. Instead, he puts locum or part-timers on the schedule, even on weeks when he is available. We all know that the hospital is paying him extra to take care of administrative work, and that it costs more for the hospital to pay part-time/locums. In your experience, is this a common occurrence? Should we be upset? Lastly, should we bring this issue to administration, because many of us think that they are not aware this is happening.

–Mismatched in the Midwest

Dr. Hospitalist responds:

Opinions vary when it comes to the amount of clinical time hospitalist leaders should devote to their groups. As we have become more involved in the administrative aspects of the hospital, there are increasing demands placed on directors. Along with increased administrative demands comes the desire of many of these physician-leaders to remain adept in the practice of hospital medicine. Without a strong clinical connection and familiarity with what the others experience day to day, the group leader risks losing credibility and whatever leverage the title might offer.

Many groups have devised formulas based on the number of members in the group to help them derive a “fair” amount of administrative time to allow the director. For example, for every five full-time equivalents (FTEs) on staff, the director receives 0.1 FTE in admin time; so, for a group of 25 members, the director would get 0.5 admin time. The remainder of time would be clinical, but again, how that clinical time is managed is also highly variable.

This seems like a reasonable formula to me, because those with larger programs will have larger hospitals, more people to manage, and more personalities to deal with. The potential rewards and job satisfaction are also greater. (Another potential scheduling issue: Does the group leader “fall right into” the rotation or only work the services with light census or teaching services in an academic institution?)

Some groups that work the traditional seven-on/seven-off schedule have allowed the hospitalist physician-leader to work Monday through Friday and carry a smaller census (10-12). This allows the leader to be in the hospital during those critical times when most administrative duties are fulfilled, while also allowing for a mechanism to place overflow patients on those high census days—as long as it is a rare occurrence. He or she should also occasionally work all the different shifts (nocturnist, admitter, teams, and so on) to best understand the group’s opportunities for improvement and its challenges.

There are likely as many iterations of how to devise a fair division of time as there are hospitalist groups, but, most importantly, the days of getting someone to volunteer to be a hospitalist director without some form of compensation are long gone. In most programs, the job has become much more complex.

Many believe it is a conflict of interest for the group leader to prepare the schedule. There is too much room for perceived favoritism or mistreatment by the members when the schedule doesn’t work in everyone’s favor (which it never will). There are proprietary programs on the market that allow for easy and reliable scheduling; they also remove the potential for bias. In a group as small as yours, an astute administrative assistant or associate director can be entrusted with the schedule.

With regard to speaking up, you say a “few” in your group are concerned, so I assume more than one but still a small number of your group has expressed some dissatisfaction. There may be other members with similar sentiments, so it is important to have a discussion with all the group members and solicit their opinions. Instead of approaching the administrators with your concerns, I suggest you and your colleagues have an open and candid discussion with your group leader. After the discussion, if you still remain dissatisfied with the director’s level of clinical involvement, you are left with several choices:

1. Approach hospital administration and see if they approve of how your director is carrying out his clinical responsibilities. Be prepared for the director to find out.
2. Continue to do your job and let this issue rest.
3. Start looking for another job. If the situation really bothers you, I favor the latter!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

The environment that breeds the formation of accountable care organizations (ACOs) includes large integrated hospital systems, primary care physicians (PCPs) practicing in large groups, and a greater fraction of hospital risk sharing, according to a Health Affairs report (http://content.healthaffairs.org/content/32/10/1781.abstract).

In other words, institutions and areas that have begun embracing risk-based or population-based payment models are more likely to spur the formation of ACOs, which have similar risk-reward payment structures.

For hospitalists, knowing the conditions that help foster ACOs may be an important first step in pushing for development and continued growth, says Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair and chief medical officer of Cogent HMG in Brentwood, Tenn.

It’s a shift in mindset for sure, says the report’s lead author.

“The traditional model is pretty much fill your beds with high-paying patients. An ACO is really a different kind of concept,” says David Auerbach, MS, PhD, of Boston-based RAND Corporation. “A hospital that doesn’t have any experience thinking in a different way is going to find it hard to accommodate the ACO payment model. But hospitals that do…probably have staff that have thought about this and already started to move down the path to thinking about ways to reduce their costs.”

Regional Variance

Dr. Auerbach, a policy researcher and affiliate faculty member at Pardee RAND Graduate School, says further work needs to be done to identify “key regional factors” that induce certain physicians and hospitals to launch ACOs. His paper, “Accountable Care Organization Formation Is Associated with Integrated Systems but Not High Medical Spending,” found wide disparities in ACO formation; the model is popular in the Northeast and Midwest regions but scarcely found in the Northwest.

The authors reviewed 32 Medicare Pioneer ACOs, 116 Medicare Shared Savings Program ACOs, and 77 private-market entities very similar to ACOs. The study’s multiple-regression analysis found that in the 31 regions with at least 20% of Medicare fee-for-service beneficiaries in an ACO, more than half of hospitals had a joint venture with doctors or physician groups and were affiliated with a health system. In so-called “low-ACO areas,” that percentage hovered around 30% to 40%.

And while much of the policy discussion focuses on whether ACOs can rein in healthcare spending in some of the markets where care costs the most, the study reported “no strong pattern in the relationship between ACO penetration and Medicare spending or spending growth.”

Uncertain Upside

Dr. Auerbach says that while the results of his paper did not surprise him, he hopes hospitalists and others use them educationally.

“We might think about there being demand from people in other areas that might say, ‘I want to be a part of that too. Why aren’t there any ACOs that I can be in?’” he adds. “And so a study like this says, ‘Here are some of the things that seem to be important.’ If there’s not this kind of infrastructure in your area, as a policy maker, you could go and say, ‘Let’s try and give a boost to some of these factors or proxies for these things.’”

Part of that review would include looking at those areas that saw higher rates of physician-institution consolidation and figuring out what the motivations were. Typically, the impetus of forming larger groups is partly explained by a desire to negotiate with insurers and get better deals, Dr. Auerbach says. But with more coordinated care comes a more efficient system that can offset those lower rates.

“I think right now most policymakers are not sure if the upside is better than the downside,” he adds. “I think the answer, personally, is not to try to break up providers and do a lot of anti-trust activity. We need to understand whether, and how much, integrated groups are able to use market power to charge higher prices. And, if they do, there may be other ways to combat that problem while keeping the groups intact.”

Rethinking Reimbursement

Dr. Greeno says growing pains are inevitable along the way, particularly because the move to the ACO payment model is a seismic shift for a healthcare industry that has traditionally been based on a fee-for-service model.

“How we pay for healthcare in this country is going to be completely flipped on its head,” he says. “Part of the goal, of course, is better outcomes for patients. But it’s also cost efficiency. In the meantime, the entire system for 100 years has been paying for production.”

Dr. Greeno compares it to the shift that was the managed-care movement. Moving forward, the shift will create winners and losers and most likely will result in massive consolidation of healthcare organizations—from nearly 700 today to what Dr. Greeno believes may be 50 to 70 mega-providers.

“It’s basically what happened when HMOs started paying capitated payments to physician groups,” he says. “The groups then had X amount of dollars to care for their patient population, and if they couldn’t make that work, they went out of business or were acquired by more successful groups. If they could make it work, then they survived. It’s the exact same thing. It’s not quite as dramatic, as it is not going to happen overnight, but that’s where it’s heading.

“And instead of occurring in pockets around the country like in Southern California and Minneapolis, it’s going to be nationwide, and the world’s largest insurance company, which is Medicare, is driving it.”

Dr. Auerbach notes that while the disruption already has caused some groups to drop out of the ACO programs, he does not see that as a precursor to more organizations turning away from the program, particularly as it is among the key planks of the general healthcare reform movement.

“It is part of a larger wave that really is changing the way we do healthcare,” he says. “I think that as [ACOs] grow...people are going to say that this is becoming something like the dominant form of delivering healthcare.”

Richard Quinn is a freelance writer in New Jersey.

The environment that breeds the formation of accountable care organizations (ACOs) includes large integrated hospital systems, primary care physicians (PCPs) practicing in large groups, and a greater fraction of hospital risk sharing, according to a Health Affairs report (http://content.healthaffairs.org/content/32/10/1781.abstract).

In other words, institutions and areas that have begun embracing risk-based or population-based payment models are more likely to spur the formation of ACOs, which have similar risk-reward payment structures.

For hospitalists, knowing the conditions that help foster ACOs may be an important first step in pushing for development and continued growth, says Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair and chief medical officer of Cogent HMG in Brentwood, Tenn.

It’s a shift in mindset for sure, says the report’s lead author.

“The traditional model is pretty much fill your beds with high-paying patients. An ACO is really a different kind of concept,” says David Auerbach, MS, PhD, of Boston-based RAND Corporation. “A hospital that doesn’t have any experience thinking in a different way is going to find it hard to accommodate the ACO payment model. But hospitals that do…probably have staff that have thought about this and already started to move down the path to thinking about ways to reduce their costs.”

Regional Variance

Dr. Auerbach, a policy researcher and affiliate faculty member at Pardee RAND Graduate School, says further work needs to be done to identify “key regional factors” that induce certain physicians and hospitals to launch ACOs. His paper, “Accountable Care Organization Formation Is Associated with Integrated Systems but Not High Medical Spending,” found wide disparities in ACO formation; the model is popular in the Northeast and Midwest regions but scarcely found in the Northwest.

The authors reviewed 32 Medicare Pioneer ACOs, 116 Medicare Shared Savings Program ACOs, and 77 private-market entities very similar to ACOs. The study’s multiple-regression analysis found that in the 31 regions with at least 20% of Medicare fee-for-service beneficiaries in an ACO, more than half of hospitals had a joint venture with doctors or physician groups and were affiliated with a health system. In so-called “low-ACO areas,” that percentage hovered around 30% to 40%.

And while much of the policy discussion focuses on whether ACOs can rein in healthcare spending in some of the markets where care costs the most, the study reported “no strong pattern in the relationship between ACO penetration and Medicare spending or spending growth.”

Uncertain Upside

Dr. Auerbach says that while the results of his paper did not surprise him, he hopes hospitalists and others use them educationally.

“We might think about there being demand from people in other areas that might say, ‘I want to be a part of that too. Why aren’t there any ACOs that I can be in?’” he adds. “And so a study like this says, ‘Here are some of the things that seem to be important.’ If there’s not this kind of infrastructure in your area, as a policy maker, you could go and say, ‘Let’s try and give a boost to some of these factors or proxies for these things.’”

Part of that review would include looking at those areas that saw higher rates of physician-institution consolidation and figuring out what the motivations were. Typically, the impetus of forming larger groups is partly explained by a desire to negotiate with insurers and get better deals, Dr. Auerbach says. But with more coordinated care comes a more efficient system that can offset those lower rates.

“I think right now most policymakers are not sure if the upside is better than the downside,” he adds. “I think the answer, personally, is not to try to break up providers and do a lot of anti-trust activity. We need to understand whether, and how much, integrated groups are able to use market power to charge higher prices. And, if they do, there may be other ways to combat that problem while keeping the groups intact.”

Rethinking Reimbursement

Dr. Greeno says growing pains are inevitable along the way, particularly because the move to the ACO payment model is a seismic shift for a healthcare industry that has traditionally been based on a fee-for-service model.

“How we pay for healthcare in this country is going to be completely flipped on its head,” he says. “Part of the goal, of course, is better outcomes for patients. But it’s also cost efficiency. In the meantime, the entire system for 100 years has been paying for production.”

Dr. Greeno compares it to the shift that was the managed-care movement. Moving forward, the shift will create winners and losers and most likely will result in massive consolidation of healthcare organizations—from nearly 700 today to what Dr. Greeno believes may be 50 to 70 mega-providers.

“It’s basically what happened when HMOs started paying capitated payments to physician groups,” he says. “The groups then had X amount of dollars to care for their patient population, and if they couldn’t make that work, they went out of business or were acquired by more successful groups. If they could make it work, then they survived. It’s the exact same thing. It’s not quite as dramatic, as it is not going to happen overnight, but that’s where it’s heading.

“And instead of occurring in pockets around the country like in Southern California and Minneapolis, it’s going to be nationwide, and the world’s largest insurance company, which is Medicare, is driving it.”

Dr. Auerbach notes that while the disruption already has caused some groups to drop out of the ACO programs, he does not see that as a precursor to more organizations turning away from the program, particularly as it is among the key planks of the general healthcare reform movement.

“It is part of a larger wave that really is changing the way we do healthcare,” he says. “I think that as [ACOs] grow...people are going to say that this is becoming something like the dominant form of delivering healthcare.”

Richard Quinn is a freelance writer in New Jersey.

The environment that breeds the formation of accountable care organizations (ACOs) includes large integrated hospital systems, primary care physicians (PCPs) practicing in large groups, and a greater fraction of hospital risk sharing, according to a Health Affairs report (http://content.healthaffairs.org/content/32/10/1781.abstract).

In other words, institutions and areas that have begun embracing risk-based or population-based payment models are more likely to spur the formation of ACOs, which have similar risk-reward payment structures.

For hospitalists, knowing the conditions that help foster ACOs may be an important first step in pushing for development and continued growth, says Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair and chief medical officer of Cogent HMG in Brentwood, Tenn.

It’s a shift in mindset for sure, says the report’s lead author.

“The traditional model is pretty much fill your beds with high-paying patients. An ACO is really a different kind of concept,” says David Auerbach, MS, PhD, of Boston-based RAND Corporation. “A hospital that doesn’t have any experience thinking in a different way is going to find it hard to accommodate the ACO payment model. But hospitals that do…probably have staff that have thought about this and already started to move down the path to thinking about ways to reduce their costs.”

Regional Variance

Dr. Auerbach, a policy researcher and affiliate faculty member at Pardee RAND Graduate School, says further work needs to be done to identify “key regional factors” that induce certain physicians and hospitals to launch ACOs. His paper, “Accountable Care Organization Formation Is Associated with Integrated Systems but Not High Medical Spending,” found wide disparities in ACO formation; the model is popular in the Northeast and Midwest regions but scarcely found in the Northwest.

The authors reviewed 32 Medicare Pioneer ACOs, 116 Medicare Shared Savings Program ACOs, and 77 private-market entities very similar to ACOs. The study’s multiple-regression analysis found that in the 31 regions with at least 20% of Medicare fee-for-service beneficiaries in an ACO, more than half of hospitals had a joint venture with doctors or physician groups and were affiliated with a health system. In so-called “low-ACO areas,” that percentage hovered around 30% to 40%.

And while much of the policy discussion focuses on whether ACOs can rein in healthcare spending in some of the markets where care costs the most, the study reported “no strong pattern in the relationship between ACO penetration and Medicare spending or spending growth.”

Uncertain Upside

Dr. Auerbach says that while the results of his paper did not surprise him, he hopes hospitalists and others use them educationally.

“We might think about there being demand from people in other areas that might say, ‘I want to be a part of that too. Why aren’t there any ACOs that I can be in?’” he adds. “And so a study like this says, ‘Here are some of the things that seem to be important.’ If there’s not this kind of infrastructure in your area, as a policy maker, you could go and say, ‘Let’s try and give a boost to some of these factors or proxies for these things.’”

Part of that review would include looking at those areas that saw higher rates of physician-institution consolidation and figuring out what the motivations were. Typically, the impetus of forming larger groups is partly explained by a desire to negotiate with insurers and get better deals, Dr. Auerbach says. But with more coordinated care comes a more efficient system that can offset those lower rates.

“I think right now most policymakers are not sure if the upside is better than the downside,” he adds. “I think the answer, personally, is not to try to break up providers and do a lot of anti-trust activity. We need to understand whether, and how much, integrated groups are able to use market power to charge higher prices. And, if they do, there may be other ways to combat that problem while keeping the groups intact.”

Rethinking Reimbursement

Dr. Greeno says growing pains are inevitable along the way, particularly because the move to the ACO payment model is a seismic shift for a healthcare industry that has traditionally been based on a fee-for-service model.

“How we pay for healthcare in this country is going to be completely flipped on its head,” he says. “Part of the goal, of course, is better outcomes for patients. But it’s also cost efficiency. In the meantime, the entire system for 100 years has been paying for production.”

Dr. Greeno compares it to the shift that was the managed-care movement. Moving forward, the shift will create winners and losers and most likely will result in massive consolidation of healthcare organizations—from nearly 700 today to what Dr. Greeno believes may be 50 to 70 mega-providers.

“It’s basically what happened when HMOs started paying capitated payments to physician groups,” he says. “The groups then had X amount of dollars to care for their patient population, and if they couldn’t make that work, they went out of business or were acquired by more successful groups. If they could make it work, then they survived. It’s the exact same thing. It’s not quite as dramatic, as it is not going to happen overnight, but that’s where it’s heading.

“And instead of occurring in pockets around the country like in Southern California and Minneapolis, it’s going to be nationwide, and the world’s largest insurance company, which is Medicare, is driving it.”

Dr. Auerbach notes that while the disruption already has caused some groups to drop out of the ACO programs, he does not see that as a precursor to more organizations turning away from the program, particularly as it is among the key planks of the general healthcare reform movement.

“It is part of a larger wave that really is changing the way we do healthcare,” he says. “I think that as [ACOs] grow...people are going to say that this is becoming something like the dominant form of delivering healthcare.”

Richard Quinn is a freelance writer in New Jersey.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

He doesn’t own a single Apple product. He hasn’t had a chance but can’t wait to watch “Zero Dark Thirty,” the docudrama that details the black ops mission to kill Osama bin Laden. And he doesn’t know what he’d do if he wasn’t a hospitalist.

A well-rounded hospitalist, that is.

Anand Kartha, MD, MS, is as engaged as hospital-based physicians come, working in the academic, research, community, and Veterans Affairs settings.

He studied at the University of Bombay in his native India, completing a four-year residency there before working as a resident and chief resident at the University of Pittsburgh Medical Center Mercy. He went on to complete a general medicine fellowship at Boston University and, in 2005, earned a Master of Science in Health Services Research at Boston University.

Currently, he is an academic hospitalist at the Boston VA and associate chief of general internal medicine. He is an assistant professor of medicine at Boston University School of Medicine and a lecturer in medicine at Harvard Medical School.

Dr. Kartha has been published a half dozen times and presented scientific abstract posters at HM12 in San Diego, HM10 in Washington, D.C., and HM09 in Chicago. He’s on the patient safety, systems redesign, professional standards, and peer review committees at the VA Boston Healthcare System. In 2007, he received the David Littmann Award for Excellence in Patient Care and Education from VA Boston and, in 2011, received the Robert Dawson Evans Faculty Special Recognition Teaching Award from Boston University.

“I spend about 15% to 20% of my time in research and 20% of my time in education, both focused on quality and patient safety,” says Dr. Kartha, one of nine new members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist. “For example, I am part of a national study to look at the quality of inpatient medicine care in the VA. I started and run a curriculum/rotation for medicine residents on quality and safety. I have held a number of leadership roles, like associate chief of medicine for quality and performance. I also enjoy working with system engineers on a number of QI projects.”

Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

–Dr. Kartha

Question: Why did you choose a career in medicine?

A: Peer pressure; an interest in biology; desire to make a direct difference in people’s lives.

Q: When did you decide to become a hospitalist?

A: About 10 years ago. My research, clinical, and educational goals all overlapped in the inpatient arena and it was a natural progression.

Q: What do you like most about working as a hospitalist?

A: Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

Q: What’s the best advice you ever received?

A: Don’t be the first to adopt a new treatment, but don’t be the last.

Q: What’s the biggest change you’ve seen in hospital medicine in your career?

A: Explosive growth. I never anticipated it would get to be so big, so fast.

Q: What is your biggest professional challenge?

A: Finding adequate mentorship and statistical support to do research and publish papers.

Q: What is your biggest professional reward?

A: Seeing my patients get better, watching my students get excited by medicine, and the success of my mentees.

Q: When you aren’t working, what is important to you?

A: Like most people, my family and health.

Q: What’s next professionally?

A: I have considered academic and medical industry leadership roles, but I see myself probably spending more time formally in inpatient clinical education.

Q: If you weren’t a doctor, what would you be doing right now?

A: I couldn’t do anything else. No skills, no interest—and I love what I do.

Q: What’s the best book you’ve read recently? Why?

A: “Sweet Tooth” by Ian McEwan. Pure entertainment.

Richard Quinn is a freelance writer in New Jersey.

He doesn’t own a single Apple product. He hasn’t had a chance but can’t wait to watch “Zero Dark Thirty,” the docudrama that details the black ops mission to kill Osama bin Laden. And he doesn’t know what he’d do if he wasn’t a hospitalist.

A well-rounded hospitalist, that is.

Anand Kartha, MD, MS, is as engaged as hospital-based physicians come, working in the academic, research, community, and Veterans Affairs settings.

He studied at the University of Bombay in his native India, completing a four-year residency there before working as a resident and chief resident at the University of Pittsburgh Medical Center Mercy. He went on to complete a general medicine fellowship at Boston University and, in 2005, earned a Master of Science in Health Services Research at Boston University.

Currently, he is an academic hospitalist at the Boston VA and associate chief of general internal medicine. He is an assistant professor of medicine at Boston University School of Medicine and a lecturer in medicine at Harvard Medical School.

Dr. Kartha has been published a half dozen times and presented scientific abstract posters at HM12 in San Diego, HM10 in Washington, D.C., and HM09 in Chicago. He’s on the patient safety, systems redesign, professional standards, and peer review committees at the VA Boston Healthcare System. In 2007, he received the David Littmann Award for Excellence in Patient Care and Education from VA Boston and, in 2011, received the Robert Dawson Evans Faculty Special Recognition Teaching Award from Boston University.

“I spend about 15% to 20% of my time in research and 20% of my time in education, both focused on quality and patient safety,” says Dr. Kartha, one of nine new members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist. “For example, I am part of a national study to look at the quality of inpatient medicine care in the VA. I started and run a curriculum/rotation for medicine residents on quality and safety. I have held a number of leadership roles, like associate chief of medicine for quality and performance. I also enjoy working with system engineers on a number of QI projects.”

Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

–Dr. Kartha

Question: Why did you choose a career in medicine?

A: Peer pressure; an interest in biology; desire to make a direct difference in people’s lives.

Q: When did you decide to become a hospitalist?

A: About 10 years ago. My research, clinical, and educational goals all overlapped in the inpatient arena and it was a natural progression.

Q: What do you like most about working as a hospitalist?

A: Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

Q: What’s the best advice you ever received?

A: Don’t be the first to adopt a new treatment, but don’t be the last.

Q: What’s the biggest change you’ve seen in hospital medicine in your career?

A: Explosive growth. I never anticipated it would get to be so big, so fast.

Q: What is your biggest professional challenge?

A: Finding adequate mentorship and statistical support to do research and publish papers.

Q: What is your biggest professional reward?

A: Seeing my patients get better, watching my students get excited by medicine, and the success of my mentees.

Q: When you aren’t working, what is important to you?

A: Like most people, my family and health.

Q: What’s next professionally?

A: I have considered academic and medical industry leadership roles, but I see myself probably spending more time formally in inpatient clinical education.

Q: If you weren’t a doctor, what would you be doing right now?

A: I couldn’t do anything else. No skills, no interest—and I love what I do.

Q: What’s the best book you’ve read recently? Why?

A: “Sweet Tooth” by Ian McEwan. Pure entertainment.

Richard Quinn is a freelance writer in New Jersey.

He doesn’t own a single Apple product. He hasn’t had a chance but can’t wait to watch “Zero Dark Thirty,” the docudrama that details the black ops mission to kill Osama bin Laden. And he doesn’t know what he’d do if he wasn’t a hospitalist.

A well-rounded hospitalist, that is.

Anand Kartha, MD, MS, is as engaged as hospital-based physicians come, working in the academic, research, community, and Veterans Affairs settings.

He studied at the University of Bombay in his native India, completing a four-year residency there before working as a resident and chief resident at the University of Pittsburgh Medical Center Mercy. He went on to complete a general medicine fellowship at Boston University and, in 2005, earned a Master of Science in Health Services Research at Boston University.

Currently, he is an academic hospitalist at the Boston VA and associate chief of general internal medicine. He is an assistant professor of medicine at Boston University School of Medicine and a lecturer in medicine at Harvard Medical School.

Dr. Kartha has been published a half dozen times and presented scientific abstract posters at HM12 in San Diego, HM10 in Washington, D.C., and HM09 in Chicago. He’s on the patient safety, systems redesign, professional standards, and peer review committees at the VA Boston Healthcare System. In 2007, he received the David Littmann Award for Excellence in Patient Care and Education from VA Boston and, in 2011, received the Robert Dawson Evans Faculty Special Recognition Teaching Award from Boston University.

“I spend about 15% to 20% of my time in research and 20% of my time in education, both focused on quality and patient safety,” says Dr. Kartha, one of nine new members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist. “For example, I am part of a national study to look at the quality of inpatient medicine care in the VA. I started and run a curriculum/rotation for medicine residents on quality and safety. I have held a number of leadership roles, like associate chief of medicine for quality and performance. I also enjoy working with system engineers on a number of QI projects.”

Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

–Dr. Kartha

Question: Why did you choose a career in medicine?

A: Peer pressure; an interest in biology; desire to make a direct difference in people’s lives.

Q: When did you decide to become a hospitalist?

A: About 10 years ago. My research, clinical, and educational goals all overlapped in the inpatient arena and it was a natural progression.

Q: What do you like most about working as a hospitalist?

A: Working as a team and teaching residents and students are both very rewarding. As an academic hospitalist, I have flexible work hours that give me time to pursue both clinical and other opportunities too.

Q: What’s the best advice you ever received?

A: Don’t be the first to adopt a new treatment, but don’t be the last.

Q: What’s the biggest change you’ve seen in hospital medicine in your career?

A: Explosive growth. I never anticipated it would get to be so big, so fast.

Q: What is your biggest professional challenge?

A: Finding adequate mentorship and statistical support to do research and publish papers.

Q: What is your biggest professional reward?

A: Seeing my patients get better, watching my students get excited by medicine, and the success of my mentees.

Q: When you aren’t working, what is important to you?

A: Like most people, my family and health.

Q: What’s next professionally?

A: I have considered academic and medical industry leadership roles, but I see myself probably spending more time formally in inpatient clinical education.

Q: If you weren’t a doctor, what would you be doing right now?

A: I couldn’t do anything else. No skills, no interest—and I love what I do.

Q: What’s the best book you’ve read recently? Why?

A: “Sweet Tooth” by Ian McEwan. Pure entertainment.

Richard Quinn is a freelance writer in New Jersey.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.

Dr. Howell

I just got back from a trip to SHM headquarters in Philadelphia, and all I can say is “wow.” I was visiting there for a meeting with the staff, many SHM members and committee leaders, and the SHM board of directors. The first day we all went into a big, modern, beautiful room at SHM headquarters—there must have been more than 100 people—and we went around the room and introduced ourselves. The diversity of the staff that support our society, and the diversity of the members there, was truly breathtaking. What I saw was a microcosm of our society and our specialty.

Looking around the room, it was easy to see some aspects of our diverse organization: both genders and a variety of ethnicities and age groups were well represented. These traditional measures of diversity are critical to a healthy environment, in my opinion, and the data bear out the idea that a diverse workforce can reduce turnover and be more creative and qualified.^1,2 Our diversity is not an accident. It is part of a larger, deliberate strategy by SHM to be “the home” for healthcare professionals who provide hospital-based patient care. SHM embraces diversity, whether it’s skin deep or deeply cognitive.

Although we are continually working to enrich the traditional aspects of diversity, we are also very hard at work to make SHM a place of professional diversity.

Open and Inclusive

Over the past several years, SHM has worked hard to be openly inclusive. Many of the committees and sections within the society have been developed specifically to embrace important aspects of hospital medicine that have special or common interests, characteristics, or needs. Examples include the international section, med-peds section, administrators’ committee, and the nurse practitioner and physician assistant committee. These venues allow individuals under a Big Tent to find others with similar interests or training, so that they can address unique aspects of hospital medicine as it relates directly to them. SHM’s virtual world is following our committee and section structure, which has some of the most actively growing HMXchange communities coming from the “administrators” community and the “NP/PA” community.

SHM has put its money where its mouth is, dedicating significant resources for educational programs that will help benefit professionals with a variety of backgrounds. Some are focused on the special needs of our diverse physician population, including the Academic Hospitalist Academy, the Quality and Safety Educators Academy, and the Pediatric Hospital Medicine annual meeting (through a partnership with the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association). Other events are focused specifically on helping our non-physician colleagues, like the boot camp that is presented in collaboration with the American Academy of Physician Assistants and American Association of Nurse Practitioners. The SHM Leadership Academies attract a venerable alphabet soup of professional designations, including many MDs and DOs, of course, but also increasing numbers of PAs and NPs, a growing number of administrators, and now even a few ED and OB docs! Now that’s a Big Tent.

My understanding is that these events are always popular and often sold out.

Maybe the most powerful evidence that our Big Tent philosophy is working is found in the relationships SHM has forged with other hospital-based specialties, like obstetrics, neurology, and surgery. The president of the Society of OB/GYN Hospitalists (societyofobgynhospitalists.com) has attended the SHM annual meeting and at least one of the Leadership Academies. Although “traditional” hospitalists like me may not be able to help in the OR or birthing suite, we have a lot of experience in quality improvement, leadership, and, of course, addressing the needs of a new and growing professional segment. The emergence and growth of these “specialty hospitalists” offers a unique opportunity for traditional hospitalists to partner with our subspecialty colleagues in a new way, so that together we can continue to improve patient care within the hospital across multiple disciplines.

What’s Ahead?

Based on the data I recently saw while at SHM headquarters, the Big Tent philosophy is a measurable success. Membership for NPs, PAs, and administrators is growing, with nearly 200 new members in those categories combined. Incredibly, we have ED physicians joining our organization—albeit, at a number dwarfed by internists—and the relationships with the specialty hospitalists are moving forward in a meaningful way. Looking at committees and committee chairs, there is plenty of ethnic, professional, and gender diversity.

What does all of this focus outside of internal medicine and physician groups mean for us internists? Will we be left behind? Fret not. Physicians make up more than 85% of our 12,000-plus members, with internists outnumbering—by a huge number—all of the other segments of our society combined. There is no Big Tent so large that physicians, or even internists, will ever be in jeopardy. We occupy plenty of space under this Big Tent and still have lots of room to spare for our colleagues. In welcoming others, we all strengthen our own standing, by elevating the entire field.

As a terrific mentor once said, a rising tide floats all boats. And the way to raise the tide of hospital medicine can be through partnerships whose gravity is a strong pull on the hospital medicine tide, as the moon pulls the ocean’s tides.

One area in which our society plans to place more effort in expanding the Big Tent is with trainees. Students and housestaff are one of the smallest groups in our organization, with the smallest growth. Those statistics are cause for concern. The need for future hospitalist growth, both in numbers and skill set, makes attracting this segment of paramount importance, in my view.

Fortunately, SHM is developing a strategy to make our society a valuable home to trainees. I have touched on those strategies previously, including a Physicians in Training Committee, free membership for students, $100 memberships for housestaff, and our “1,000 Challenge” to recruit 1,000 students and housestaff in the coming months.

In Sum

I am a firm believer in professional and personal diversity. I am proud to work in a society that also embraces this philosophy, places real value on it, and works hard to be inclusive. So, the next time you meet an NP, PA, student, or even a hospital-based OB physician, bring them under the SHM Big Tent, and encourage them to join us in making the hospital world a better place. They, we, and our patients will be better off for it.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Egan ME. Global diversity and inclusion: Fostering innovation through a diverse workforce. Forbes Insights. Forbes website. Available at: http://images.forbes.com/forbesinsights/StudyPDFs/Innovation_Through_Diversity.pdf. Accessed October 23, 2013.
2. Kerby S, Burns C. The top 10 economic facts of diversity in the workplace. Center for American Progress website. Available at: http://www.americanprogress.org/issues/labor/news/2012/07/12/11900/the-top-10-economic-facts-of-diversity-in-the-workplace. Accessed October 23, 2013.