Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Clinical question: What is the long-term outcome of elderly survivors of in-hospital cardiac arrest?

Background: Previous studies have examined in-hospital survival from in-hospital cardiac arrest but have not looked at long-term outcomes and readmission of in-hospital cardiac arrest survivors.

Study design: Retrospective cohort.

Setting: Acute-care hospitals that submitted data to the Get with the Guidelines—Resuscitation registry between 2000 and 2008.

Synopsis: Using the Get with the Guidelines—Resuscitation registry from 401 acute-care hospitals, data from 6,972 Medicare patients aged 65 years or older who had a pulseless in-hospital cardiac arrest and survived to discharge were analyzed. Survival rates were 82% at 30 days, 72% at three months, 58.5% at one year, and 49.6% at two years. Survival at three years was 43.5%, similar to patients discharged with heart failure.

One-year survival decreased with increasing age. Survival also decreased with black race (52.5% vs. 60.4% for white patients, P=0.001) and male sex (58.6% vs. 60.9% for women, P=0.03). Patients with mild or no neurologic disability at discharge had a higher survival rate at one year than patients with moderate, severe, or coma state. Readmission rates at one year after discharge were 65.6% and 76.2% at two years. Black patients, women, and patients with neurologic disability at discharge were more likely to be readmitted.

Because this is an observational study looking at a quality database of Medicare patients, it excludes patients at VA hospitals and non-Medicare facilities. This data excludes assessments of quality of life after discharge and health status among those with long-term survival, and does not include cause of death.

Bottom line: One-year survival following in-hospital cardiac arrest for patients over age 65 approaches 60% and decreases with increasing age, male sex, and black race.

Citation: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med. 2013;368:1019-1026.

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Click here to listen to excerpts of Dr. Duke's interview with The Hospitalist

Click here to listen to excerpts of Dr. Parkhurst's interview with The Hospitalist

Click here to listen to excerpts of Dr. Parkhurst's interview with The Hospitalist

Click here to listen to excerpts of Dr. Parkhurst's interview with The Hospitalist

Click here to listen to excerpts of Dr. Chretien's interview with The Hospitalist

Click here to listen to excerpts of Dr. Chretien's interview with The Hospitalist

Click here to listen to excerpts of Dr. Chretien's interview with The Hospitalist

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients.”

—James Hudspeth, MD, Boston Medical Center

“At some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available. ”

—Dan Hale, MD, Floating Hospital for Children at Tufts Medical Center, Boston

Dan Hale, MD, a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, was doing discharge paperwork when he started getting text messages he couldn’t quite interpret.

“Are you OK?” “Do you need anything?” friends were asking him. Then he heard a page for all anesthesiologists to report to the OR. Immediately, he knew something terrible must have happened. He soon learned about the bombings at the Boston Marathon. He rushed to the pediatric ED to see how he could help.

James Hudspeth, MD, a hospitalist at Boston Medical Center, was meeting with the program director for internal medicine when he read a text message that bombs had just gone off near the finish line. They went online for local news coverage; soon thereafter, a cap on admissions was lifted. Dr. Hudspeth started expediting discharges to make room for what might be coming the hospital’s way.

Sushrut Jangi, MD, a hospitalist at Beth Israel Deaconess Medical Center, was in a medical tent gathering information for an article on treating the health problems of marathoners that he was writing for The Boston Globe when he heard the blasts. Doctors and medical staff there worried about the possibility of a bomb in the tent, he said, but they were instructed to stay with their patients. Dr. Jangi had expected to work as a journalist for the day, but his doctoring skills were needed.

Hospitalists who were working in downtown Boston on April 15, when two bombs exploded 17 seconds apart, all experienced the tragedy in their own ways. But their accounts also resonate within some of the same themes.

They found themselves unsure of their roles, as most of the work inevitably fell to surgeons and trauma specialists. They described the importance of good leadership in times of crisis. And they say that hospitalists should be incorporated to a greater extent into disaster plans.

Dr. Jangi said that before the bombs went off, the medical tent was almost filled with runners who were “quite ill”—hypothermic and shaking, high sodium levels, disoriented. When the blasts occurred, the main instruction was, “Don’t leave your patients behind.” Those who were well enough were released from the tent, and the bomb-blast victims were essentially “whisked through.”

“We just kind of cleared the way and got them into ambulances as soon as possible. We just didn’t have the capacity to take care of such severe injury,” he said. “Why should we? We weren’t expecting a war zone.”

In the tent, Dr. Jangi wrote in an essay for the New England Journal of Medicine, “Many of us barely laid our hands on anyone. We had no trauma surgeons or supplies of blood products; tourniquets had already been applied; CPR had already been performed. Though some patients required bandages, sutures, and dressings, many of us watched these passing victims in a kind of idle horror, with no idea how to help.”

Dr. Hale was not involved in the treatment of bombing victims as the attending of record, but he said that he had a “bird’s-eye view” of the response in the pediatric ED. One child had shrapnel injuries and a ruptured tympanic membrane and was worked on by the team “professionally and efficiently,” Dr. Hale said.

When reports of a possible third bomb blast, at a library, came in, he saw the physician leaders go from team to team, making sure they were prepared.

“There were clear leaders communicating what to do,” said Dr. Hale, a firefighter in his hometown of Kittery in southern Maine. “As patients came in, it was extremely orderly. I saw very few clinical staff who were rattled.”

For his own part, in addition to his medical training, his training as a firefighter helped keep him calm, he said.

At Boston Medical Center, about a mile and a half from the blasts, the admissions that had been worked up over the course of the afternoon were essentially taken all at once so that there was room in the ED, said Dr. Hudspeth, who also does medical work in Haiti and was in New York on 9/11, though not as a doctor.

Focusing, he said, was “definitely a challenge.” Even though he had faith in hospital security, there was still “some notion of ‘You never know exactly what’s going to happen.’”

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients,” he said. “By and large, just put your nose to the grindstone.”

The doctors said that hospitalists had an unclear role in the response effort and hope to have their roles clarified so that they can better put to use their expertise in internal medicine. If hospitalists are monitoring general medical issues, that will help take some of the pressure off the trauma team.

“We know the [general] medicine stuff very well—that is our bread and butter,” said Dr. Hudspeth, who added that steps are being taken as part of Boston Medical Center’s post-response analysis to determine hospitalists’ role in future disaster responses.

They also said they felt fortunate that the bombings had occurred where they did, with so many hospitals close to the scene. It kept the system from becoming overwhelmed. Even so, “at some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available,” Dr. Hale added.

Dr. Jangi said that he thinks his residency training helped him when he found himself having to provide care in a high-pressure situation in the medical tent.

“During residency, there are a lot of situations where you’re responsible for making a decision on your feet,” he said. “That’s a skill that you’re not really exposed to until you do it and that type of fast decision-making. I felt myself drawing on that. Not that I resuscitated anyone in the tent, but I felt more comfortable with uncertainty, with doing your duty in a situation of uncertainty. And I don’t know—maybe if I hadn’t gone through that, I would have just run out of there.”

He said the experience has helped make him more committed as a doctor.

“It makes it easier to remember what my duty is more, and it just gives me more empathy for suffering in general—I feel that very strongly,” he said. “It’s possible that this experience could have numbed me, but it didn’t. It’s made me more acute to the idea of people suffering.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Under the Medical Tent at the Boston Marathon. N Engl J Med. 2013;368:1953-1955.

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients.”

—James Hudspeth, MD, Boston Medical Center

“At some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available. ”

—Dan Hale, MD, Floating Hospital for Children at Tufts Medical Center, Boston

Dan Hale, MD, a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, was doing discharge paperwork when he started getting text messages he couldn’t quite interpret.

“Are you OK?” “Do you need anything?” friends were asking him. Then he heard a page for all anesthesiologists to report to the OR. Immediately, he knew something terrible must have happened. He soon learned about the bombings at the Boston Marathon. He rushed to the pediatric ED to see how he could help.

James Hudspeth, MD, a hospitalist at Boston Medical Center, was meeting with the program director for internal medicine when he read a text message that bombs had just gone off near the finish line. They went online for local news coverage; soon thereafter, a cap on admissions was lifted. Dr. Hudspeth started expediting discharges to make room for what might be coming the hospital’s way.

Sushrut Jangi, MD, a hospitalist at Beth Israel Deaconess Medical Center, was in a medical tent gathering information for an article on treating the health problems of marathoners that he was writing for The Boston Globe when he heard the blasts. Doctors and medical staff there worried about the possibility of a bomb in the tent, he said, but they were instructed to stay with their patients. Dr. Jangi had expected to work as a journalist for the day, but his doctoring skills were needed.

Hospitalists who were working in downtown Boston on April 15, when two bombs exploded 17 seconds apart, all experienced the tragedy in their own ways. But their accounts also resonate within some of the same themes.

They found themselves unsure of their roles, as most of the work inevitably fell to surgeons and trauma specialists. They described the importance of good leadership in times of crisis. And they say that hospitalists should be incorporated to a greater extent into disaster plans.

Dr. Jangi said that before the bombs went off, the medical tent was almost filled with runners who were “quite ill”—hypothermic and shaking, high sodium levels, disoriented. When the blasts occurred, the main instruction was, “Don’t leave your patients behind.” Those who were well enough were released from the tent, and the bomb-blast victims were essentially “whisked through.”

“We just kind of cleared the way and got them into ambulances as soon as possible. We just didn’t have the capacity to take care of such severe injury,” he said. “Why should we? We weren’t expecting a war zone.”

In the tent, Dr. Jangi wrote in an essay for the New England Journal of Medicine, “Many of us barely laid our hands on anyone. We had no trauma surgeons or supplies of blood products; tourniquets had already been applied; CPR had already been performed. Though some patients required bandages, sutures, and dressings, many of us watched these passing victims in a kind of idle horror, with no idea how to help.”

Dr. Hale was not involved in the treatment of bombing victims as the attending of record, but he said that he had a “bird’s-eye view” of the response in the pediatric ED. One child had shrapnel injuries and a ruptured tympanic membrane and was worked on by the team “professionally and efficiently,” Dr. Hale said.

When reports of a possible third bomb blast, at a library, came in, he saw the physician leaders go from team to team, making sure they were prepared.

“There were clear leaders communicating what to do,” said Dr. Hale, a firefighter in his hometown of Kittery in southern Maine. “As patients came in, it was extremely orderly. I saw very few clinical staff who were rattled.”

For his own part, in addition to his medical training, his training as a firefighter helped keep him calm, he said.

At Boston Medical Center, about a mile and a half from the blasts, the admissions that had been worked up over the course of the afternoon were essentially taken all at once so that there was room in the ED, said Dr. Hudspeth, who also does medical work in Haiti and was in New York on 9/11, though not as a doctor.

Focusing, he said, was “definitely a challenge.” Even though he had faith in hospital security, there was still “some notion of ‘You never know exactly what’s going to happen.’”

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients,” he said. “By and large, just put your nose to the grindstone.”

The doctors said that hospitalists had an unclear role in the response effort and hope to have their roles clarified so that they can better put to use their expertise in internal medicine. If hospitalists are monitoring general medical issues, that will help take some of the pressure off the trauma team.

“We know the [general] medicine stuff very well—that is our bread and butter,” said Dr. Hudspeth, who added that steps are being taken as part of Boston Medical Center’s post-response analysis to determine hospitalists’ role in future disaster responses.

They also said they felt fortunate that the bombings had occurred where they did, with so many hospitals close to the scene. It kept the system from becoming overwhelmed. Even so, “at some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available,” Dr. Hale added.

Dr. Jangi said that he thinks his residency training helped him when he found himself having to provide care in a high-pressure situation in the medical tent.

“During residency, there are a lot of situations where you’re responsible for making a decision on your feet,” he said. “That’s a skill that you’re not really exposed to until you do it and that type of fast decision-making. I felt myself drawing on that. Not that I resuscitated anyone in the tent, but I felt more comfortable with uncertainty, with doing your duty in a situation of uncertainty. And I don’t know—maybe if I hadn’t gone through that, I would have just run out of there.”

He said the experience has helped make him more committed as a doctor.

“It makes it easier to remember what my duty is more, and it just gives me more empathy for suffering in general—I feel that very strongly,” he said. “It’s possible that this experience could have numbed me, but it didn’t. It’s made me more acute to the idea of people suffering.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Under the Medical Tent at the Boston Marathon. N Engl J Med. 2013;368:1953-1955.

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients.”

—James Hudspeth, MD, Boston Medical Center

“At some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available. ”

—Dan Hale, MD, Floating Hospital for Children at Tufts Medical Center, Boston

Dan Hale, MD, a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, was doing discharge paperwork when he started getting text messages he couldn’t quite interpret.

“Are you OK?” “Do you need anything?” friends were asking him. Then he heard a page for all anesthesiologists to report to the OR. Immediately, he knew something terrible must have happened. He soon learned about the bombings at the Boston Marathon. He rushed to the pediatric ED to see how he could help.

James Hudspeth, MD, a hospitalist at Boston Medical Center, was meeting with the program director for internal medicine when he read a text message that bombs had just gone off near the finish line. They went online for local news coverage; soon thereafter, a cap on admissions was lifted. Dr. Hudspeth started expediting discharges to make room for what might be coming the hospital’s way.

Sushrut Jangi, MD, a hospitalist at Beth Israel Deaconess Medical Center, was in a medical tent gathering information for an article on treating the health problems of marathoners that he was writing for The Boston Globe when he heard the blasts. Doctors and medical staff there worried about the possibility of a bomb in the tent, he said, but they were instructed to stay with their patients. Dr. Jangi had expected to work as a journalist for the day, but his doctoring skills were needed.

Hospitalists who were working in downtown Boston on April 15, when two bombs exploded 17 seconds apart, all experienced the tragedy in their own ways. But their accounts also resonate within some of the same themes.

They found themselves unsure of their roles, as most of the work inevitably fell to surgeons and trauma specialists. They described the importance of good leadership in times of crisis. And they say that hospitalists should be incorporated to a greater extent into disaster plans.

Dr. Jangi said that before the bombs went off, the medical tent was almost filled with runners who were “quite ill”—hypothermic and shaking, high sodium levels, disoriented. When the blasts occurred, the main instruction was, “Don’t leave your patients behind.” Those who were well enough were released from the tent, and the bomb-blast victims were essentially “whisked through.”

“We just kind of cleared the way and got them into ambulances as soon as possible. We just didn’t have the capacity to take care of such severe injury,” he said. “Why should we? We weren’t expecting a war zone.”

In the tent, Dr. Jangi wrote in an essay for the New England Journal of Medicine, “Many of us barely laid our hands on anyone. We had no trauma surgeons or supplies of blood products; tourniquets had already been applied; CPR had already been performed. Though some patients required bandages, sutures, and dressings, many of us watched these passing victims in a kind of idle horror, with no idea how to help.”

Dr. Hale was not involved in the treatment of bombing victims as the attending of record, but he said that he had a “bird’s-eye view” of the response in the pediatric ED. One child had shrapnel injuries and a ruptured tympanic membrane and was worked on by the team “professionally and efficiently,” Dr. Hale said.

When reports of a possible third bomb blast, at a library, came in, he saw the physician leaders go from team to team, making sure they were prepared.

“There were clear leaders communicating what to do,” said Dr. Hale, a firefighter in his hometown of Kittery in southern Maine. “As patients came in, it was extremely orderly. I saw very few clinical staff who were rattled.”

For his own part, in addition to his medical training, his training as a firefighter helped keep him calm, he said.

At Boston Medical Center, about a mile and a half from the blasts, the admissions that had been worked up over the course of the afternoon were essentially taken all at once so that there was room in the ED, said Dr. Hudspeth, who also does medical work in Haiti and was in New York on 9/11, though not as a doctor.

Focusing, he said, was “definitely a challenge.” Even though he had faith in hospital security, there was still “some notion of ‘You never know exactly what’s going to happen.’”

“You focus on the patient that’s in front of you. You focus on trying to solve the issues that are at hand. You deal with the logistical questions that come up between patients,” he said. “By and large, just put your nose to the grindstone.”

The doctors said that hospitalists had an unclear role in the response effort and hope to have their roles clarified so that they can better put to use their expertise in internal medicine. If hospitalists are monitoring general medical issues, that will help take some of the pressure off the trauma team.

“We know the [general] medicine stuff very well—that is our bread and butter,” said Dr. Hudspeth, who added that steps are being taken as part of Boston Medical Center’s post-response analysis to determine hospitalists’ role in future disaster responses.

They also said they felt fortunate that the bombings had occurred where they did, with so many hospitals close to the scene. It kept the system from becoming overwhelmed. Even so, “at some point, a disaster is so large that it would overwhelm any system, no matter how many resources were available,” Dr. Hale added.

Dr. Jangi said that he thinks his residency training helped him when he found himself having to provide care in a high-pressure situation in the medical tent.

“During residency, there are a lot of situations where you’re responsible for making a decision on your feet,” he said. “That’s a skill that you’re not really exposed to until you do it and that type of fast decision-making. I felt myself drawing on that. Not that I resuscitated anyone in the tent, but I felt more comfortable with uncertainty, with doing your duty in a situation of uncertainty. And I don’t know—maybe if I hadn’t gone through that, I would have just run out of there.”

He said the experience has helped make him more committed as a doctor.

“It makes it easier to remember what my duty is more, and it just gives me more empathy for suffering in general—I feel that very strongly,” he said. “It’s possible that this experience could have numbed me, but it didn’t. It’s made me more acute to the idea of people suffering.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Under the Medical Tent at the Boston Marathon. N Engl J Med. 2013;368:1953-1955.

What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.

—Weijen Chang, MD, SFHM, FAAP

Next month, readers of The Hospitalist will see a new face alongside the monthly “Pediatric HM Literature” column. Weijen Chang, MD, SFHM, FAAP, has been selected its new pediatric editor. Next month Dr. Chang takes over for Mark Shen, MD, SFHM, the magazine's pediatric editor since 2010.

Dr. Chang attended Duke University’s medicine-pediatrics residency program in Durham, N.C., after graduating from New York Medical College in Valhalla, N.Y. He serves as health sciences associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and serves as a hospitalist at both UCSD Medical Center and Rady Children’s Hospital, just across town from UCSD.

As pediatric editor, Dr. Chang hopes to help grow the field of pediatric hospital medicine, just as adult HM has grown over the last decade.

“In the past 10 years of HM being in existence, I think adult hospitalists have gone from being a fill-in-type player to really being leaders in their institutions,” he says, “and I think pediatric hospitalists are beginning to fill that role. What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.”

Danielle Scheurer, MD, MSCR, SFHM, The Hospitalist’s physician editor, echoed Dr. Change’s enthusiasm. “We are thrilled to have Weijen Chang as our new pediatric editor,” Dr. Scheurer says. “He is a long-time member of Team Hospitalist, active SHM member, and a respected mentor in the pediatric hospitalist community. He will bring insight and depth to the pediatric HM community. We are lucky to be able to recruit him to this position.”

Dr. Chang says he’s looking forward to his new role and new contacts he will be making. He recently joined SHM’s Pediatrics Committee, and will continue engagement with Team Hospitalist, the magazine’s editorial advisory board.

“I’m really excited to get the chance to contact other pediatric hospitalists around the country to gauge opinions about various issues that we face,” Dr. Chang says. “For me, the most exciting part is having an excuse to call people to see what’s going on in their institutions. As hospitalists, we’re so focused on what happens within our walls that we don’t get to see what’s happening elsewhere.”

Michael O’Neal is a freelance writer in New York.

What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.

—Weijen Chang, MD, SFHM, FAAP

Next month, readers of The Hospitalist will see a new face alongside the monthly “Pediatric HM Literature” column. Weijen Chang, MD, SFHM, FAAP, has been selected its new pediatric editor. Next month Dr. Chang takes over for Mark Shen, MD, SFHM, the magazine's pediatric editor since 2010.

Dr. Chang attended Duke University’s medicine-pediatrics residency program in Durham, N.C., after graduating from New York Medical College in Valhalla, N.Y. He serves as health sciences associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and serves as a hospitalist at both UCSD Medical Center and Rady Children’s Hospital, just across town from UCSD.

As pediatric editor, Dr. Chang hopes to help grow the field of pediatric hospital medicine, just as adult HM has grown over the last decade.

“In the past 10 years of HM being in existence, I think adult hospitalists have gone from being a fill-in-type player to really being leaders in their institutions,” he says, “and I think pediatric hospitalists are beginning to fill that role. What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.”

Danielle Scheurer, MD, MSCR, SFHM, The Hospitalist’s physician editor, echoed Dr. Change’s enthusiasm. “We are thrilled to have Weijen Chang as our new pediatric editor,” Dr. Scheurer says. “He is a long-time member of Team Hospitalist, active SHM member, and a respected mentor in the pediatric hospitalist community. He will bring insight and depth to the pediatric HM community. We are lucky to be able to recruit him to this position.”

Dr. Chang says he’s looking forward to his new role and new contacts he will be making. He recently joined SHM’s Pediatrics Committee, and will continue engagement with Team Hospitalist, the magazine’s editorial advisory board.

“I’m really excited to get the chance to contact other pediatric hospitalists around the country to gauge opinions about various issues that we face,” Dr. Chang says. “For me, the most exciting part is having an excuse to call people to see what’s going on in their institutions. As hospitalists, we’re so focused on what happens within our walls that we don’t get to see what’s happening elsewhere.”

Michael O’Neal is a freelance writer in New York.

What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.

—Weijen Chang, MD, SFHM, FAAP

Next month, readers of The Hospitalist will see a new face alongside the monthly “Pediatric HM Literature” column. Weijen Chang, MD, SFHM, FAAP, has been selected its new pediatric editor. Next month Dr. Chang takes over for Mark Shen, MD, SFHM, the magazine's pediatric editor since 2010.

Dr. Chang attended Duke University’s medicine-pediatrics residency program in Durham, N.C., after graduating from New York Medical College in Valhalla, N.Y. He serves as health sciences associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and serves as a hospitalist at both UCSD Medical Center and Rady Children’s Hospital, just across town from UCSD.

As pediatric editor, Dr. Chang hopes to help grow the field of pediatric hospital medicine, just as adult HM has grown over the last decade.

“In the past 10 years of HM being in existence, I think adult hospitalists have gone from being a fill-in-type player to really being leaders in their institutions,” he says, “and I think pediatric hospitalists are beginning to fill that role. What I’d like to highlight is how pediatric hospitalists can follow their adult hospitalist brothers and sisters into the role of being leaders … in how to handle challenges that their hospitals face.”

Danielle Scheurer, MD, MSCR, SFHM, The Hospitalist’s physician editor, echoed Dr. Change’s enthusiasm. “We are thrilled to have Weijen Chang as our new pediatric editor,” Dr. Scheurer says. “He is a long-time member of Team Hospitalist, active SHM member, and a respected mentor in the pediatric hospitalist community. He will bring insight and depth to the pediatric HM community. We are lucky to be able to recruit him to this position.”

Dr. Chang says he’s looking forward to his new role and new contacts he will be making. He recently joined SHM’s Pediatrics Committee, and will continue engagement with Team Hospitalist, the magazine’s editorial advisory board.

“I’m really excited to get the chance to contact other pediatric hospitalists around the country to gauge opinions about various issues that we face,” Dr. Chang says. “For me, the most exciting part is having an excuse to call people to see what’s going on in their institutions. As hospitalists, we’re so focused on what happens within our walls that we don’t get to see what’s happening elsewhere.”

Michael O’Neal is a freelance writer in New York.

Jairy C. Hunter, MD, MBA, SFHM

Associate executive medical director for case management and care transitions, Medical University of South Carolina, Charleston

QUOTABLE: “Hospital medicine is at the forefront of the changes to the way our country approaches healthcare delivery. In my view, hospitalists will play a pivotal role, through innovation, to ensure our patients receive the care they deserve in a safe and efficient manner. We should view this time as an opportunity to demonstrate the value of our expertise.”

Gregory Harlan, MD, MPH

Director of medical affairs, IPC: The Hospitalist Company, North Hollywood, Calif.; clinical instructor, University of Southern California Medical School; pediatric hospitalist, Children’s Hospital of Los Angeles

QUOTABLE: “Hospitalist medicine is defining the next iteration of acute- and post-acute care at a systems level. Hospitalists are innovative and working within their facilities to enact change. I have worked in various settings: as an academic, medical director, PCP, and acute hospitalist. I appreciate the complexity of health care today.”

Klaus Suehler, MD, FHMHospitalist, Midwest Internal Medicine Hospitalists, Mercy Hospital, Coon Rapids, Minn.

QUOTABLE: “Being a hospitalist is both a challenging and rewarding way to practice medicine. We are the patient’s advocate at a time of acute and often life-threatening illness.”

Anand Kartha, MD, MSc

Hospitalist, VA Boston Healthcare System; assistant professor of medicine, Boston University; lecturer in medicine, Harvard Medical School

QUOTABLE: “Being a hospitalist gives me the wonderful opportunity to help people in their time of acute need. Taking care of veterans in particular allows me the privilege of caring for those who help keep us safe.”

Midori Larrabee, MD

Hospitalist medical director, Valley General Hospital, Monroe, Wash.

QUOTABLE: “Hospital medicine allows me the time and flexibility to both practice clinical medicine and advocate for my patients as a physician leader.”

Bryan Weiss, MBA

Director, consulting services practice, MedSynergies, Irving, Texas

QUOTABLE: “I am passionate and believe in hospital medicine.”

James O’Callaghan, MD, FAAP, FHM

Regional pediatric hospitalist, Evergreen (Wash.) Hospital; medical hospitalist, Seattle Children’s Hospital

QUOTABLE: “As a pediatric hospitalist, I am privileged to work with patients and families during what is typically the most stressful event of their lives, and to help them successfully navigate the complexities of modern U.S. health care.”

Julie L. Fedderson, MD

Assistant professor of medicine and internal-medicine chief quality and outcomes officer, The Nebraska Medical Center, Omaha

QUOTABLE: “Being a hospitalist has provided me daily challenges and forces me

to think outside the box to obtain the best outcomes for my patients. The ability to truly steer standardization of care and evidence-based medicine is amazing. This unique opportunity to care for patients on the individual level, and still provide insight into population management, epitomizes what our goals as hospitalists should be.”

Julianna Lindsey, MD, MBA, FHM

COO and strategist, Synergy Surgicalists; lead consultant, Asynd Consulting, Nashville, Tenn.

QUOTABLE: “Being a hospitalist is the best job in medicine. Hospitalists have the satisfaction of delivering care to patients at the bedside, in addition to the opportunity to drive patient quality, safety, and satisfaction initiatives on a larger scale. It’s the best place in medicine, in my opinion.”

Jairy C. Hunter, MD, MBA, SFHM

Associate executive medical director for case management and care transitions, Medical University of South Carolina, Charleston

QUOTABLE: “Hospital medicine is at the forefront of the changes to the way our country approaches healthcare delivery. In my view, hospitalists will play a pivotal role, through innovation, to ensure our patients receive the care they deserve in a safe and efficient manner. We should view this time as an opportunity to demonstrate the value of our expertise.”

Gregory Harlan, MD, MPH

Director of medical affairs, IPC: The Hospitalist Company, North Hollywood, Calif.; clinical instructor, University of Southern California Medical School; pediatric hospitalist, Children’s Hospital of Los Angeles

QUOTABLE: “Hospitalist medicine is defining the next iteration of acute- and post-acute care at a systems level. Hospitalists are innovative and working within their facilities to enact change. I have worked in various settings: as an academic, medical director, PCP, and acute hospitalist. I appreciate the complexity of health care today.”

Klaus Suehler, MD, FHMHospitalist, Midwest Internal Medicine Hospitalists, Mercy Hospital, Coon Rapids, Minn.

QUOTABLE: “Being a hospitalist is both a challenging and rewarding way to practice medicine. We are the patient’s advocate at a time of acute and often life-threatening illness.”

Anand Kartha, MD, MSc

Hospitalist, VA Boston Healthcare System; assistant professor of medicine, Boston University; lecturer in medicine, Harvard Medical School

QUOTABLE: “Being a hospitalist gives me the wonderful opportunity to help people in their time of acute need. Taking care of veterans in particular allows me the privilege of caring for those who help keep us safe.”

Midori Larrabee, MD

Hospitalist medical director, Valley General Hospital, Monroe, Wash.

QUOTABLE: “Hospital medicine allows me the time and flexibility to both practice clinical medicine and advocate for my patients as a physician leader.”

Bryan Weiss, MBA

Director, consulting services practice, MedSynergies, Irving, Texas

QUOTABLE: “I am passionate and believe in hospital medicine.”

James O’Callaghan, MD, FAAP, FHM

Regional pediatric hospitalist, Evergreen (Wash.) Hospital; medical hospitalist, Seattle Children’s Hospital

QUOTABLE: “As a pediatric hospitalist, I am privileged to work with patients and families during what is typically the most stressful event of their lives, and to help them successfully navigate the complexities of modern U.S. health care.”

Julie L. Fedderson, MD

Assistant professor of medicine and internal-medicine chief quality and outcomes officer, The Nebraska Medical Center, Omaha

QUOTABLE: “Being a hospitalist has provided me daily challenges and forces me

to think outside the box to obtain the best outcomes for my patients. The ability to truly steer standardization of care and evidence-based medicine is amazing. This unique opportunity to care for patients on the individual level, and still provide insight into population management, epitomizes what our goals as hospitalists should be.”

Julianna Lindsey, MD, MBA, FHM

COO and strategist, Synergy Surgicalists; lead consultant, Asynd Consulting, Nashville, Tenn.

QUOTABLE: “Being a hospitalist is the best job in medicine. Hospitalists have the satisfaction of delivering care to patients at the bedside, in addition to the opportunity to drive patient quality, safety, and satisfaction initiatives on a larger scale. It’s the best place in medicine, in my opinion.”

Jairy C. Hunter, MD, MBA, SFHM

Associate executive medical director for case management and care transitions, Medical University of South Carolina, Charleston

QUOTABLE: “Hospital medicine is at the forefront of the changes to the way our country approaches healthcare delivery. In my view, hospitalists will play a pivotal role, through innovation, to ensure our patients receive the care they deserve in a safe and efficient manner. We should view this time as an opportunity to demonstrate the value of our expertise.”

Gregory Harlan, MD, MPH

Director of medical affairs, IPC: The Hospitalist Company, North Hollywood, Calif.; clinical instructor, University of Southern California Medical School; pediatric hospitalist, Children’s Hospital of Los Angeles

QUOTABLE: “Hospitalist medicine is defining the next iteration of acute- and post-acute care at a systems level. Hospitalists are innovative and working within their facilities to enact change. I have worked in various settings: as an academic, medical director, PCP, and acute hospitalist. I appreciate the complexity of health care today.”

Klaus Suehler, MD, FHMHospitalist, Midwest Internal Medicine Hospitalists, Mercy Hospital, Coon Rapids, Minn.

QUOTABLE: “Being a hospitalist is both a challenging and rewarding way to practice medicine. We are the patient’s advocate at a time of acute and often life-threatening illness.”

Anand Kartha, MD, MSc

Hospitalist, VA Boston Healthcare System; assistant professor of medicine, Boston University; lecturer in medicine, Harvard Medical School

QUOTABLE: “Being a hospitalist gives me the wonderful opportunity to help people in their time of acute need. Taking care of veterans in particular allows me the privilege of caring for those who help keep us safe.”

Midori Larrabee, MD

Hospitalist medical director, Valley General Hospital, Monroe, Wash.

QUOTABLE: “Hospital medicine allows me the time and flexibility to both practice clinical medicine and advocate for my patients as a physician leader.”

Bryan Weiss, MBA

Director, consulting services practice, MedSynergies, Irving, Texas

QUOTABLE: “I am passionate and believe in hospital medicine.”

James O’Callaghan, MD, FAAP, FHM

Regional pediatric hospitalist, Evergreen (Wash.) Hospital; medical hospitalist, Seattle Children’s Hospital

QUOTABLE: “As a pediatric hospitalist, I am privileged to work with patients and families during what is typically the most stressful event of their lives, and to help them successfully navigate the complexities of modern U.S. health care.”

Julie L. Fedderson, MD

Assistant professor of medicine and internal-medicine chief quality and outcomes officer, The Nebraska Medical Center, Omaha

QUOTABLE: “Being a hospitalist has provided me daily challenges and forces me

to think outside the box to obtain the best outcomes for my patients. The ability to truly steer standardization of care and evidence-based medicine is amazing. This unique opportunity to care for patients on the individual level, and still provide insight into population management, epitomizes what our goals as hospitalists should be.”

Julianna Lindsey, MD, MBA, FHM

COO and strategist, Synergy Surgicalists; lead consultant, Asynd Consulting, Nashville, Tenn.

QUOTABLE: “Being a hospitalist is the best job in medicine. Hospitalists have the satisfaction of delivering care to patients at the bedside, in addition to the opportunity to drive patient quality, safety, and satisfaction initiatives on a larger scale. It’s the best place in medicine, in my opinion.”