Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.

Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.

Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.

In January, the Anticoagulation Forum, a nonprofit in Newton, Mass., launched “Anti-Coagulation Centers of Excellence,” a searchable resource center of guidelines and tools, including up-to-date information on novel oral anticoagulants, examples of excellence submitted by other providers, and an online self-assessment tool of anticoagulation programs’ performance. In its first month, the site (www.excellence.acforum.org) had 1,200 visitors, with about 10% of visitors attempting the self-assessment. Participating centers tend to be hospital-based outpatient clinics for patients receiving anti-thrombotic medications.

In January, the Anticoagulation Forum, a nonprofit in Newton, Mass., launched “Anti-Coagulation Centers of Excellence,” a searchable resource center of guidelines and tools, including up-to-date information on novel oral anticoagulants, examples of excellence submitted by other providers, and an online self-assessment tool of anticoagulation programs’ performance. In its first month, the site (www.excellence.acforum.org) had 1,200 visitors, with about 10% of visitors attempting the self-assessment. Participating centers tend to be hospital-based outpatient clinics for patients receiving anti-thrombotic medications.

In January, the Anticoagulation Forum, a nonprofit in Newton, Mass., launched “Anti-Coagulation Centers of Excellence,” a searchable resource center of guidelines and tools, including up-to-date information on novel oral anticoagulants, examples of excellence submitted by other providers, and an online self-assessment tool of anticoagulation programs’ performance. In its first month, the site (www.excellence.acforum.org) had 1,200 visitors, with about 10% of visitors attempting the self-assessment. Participating centers tend to be hospital-based outpatient clinics for patients receiving anti-thrombotic medications.

As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.

The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.⁴ Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.

The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.

On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.⁵ The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.

“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.

References

1. Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
2. The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.

As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.

The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.⁴ Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.

The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.

On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.⁵ The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.

“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.

References

1. Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
2. The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.

As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.

The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.⁴ Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.

The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.

On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.⁵ The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.

“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.

References

1. Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
2. The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.

Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.¹

Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).²

Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.¹ Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.

For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.

Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”

References

1. Krumholz HM. Post-hospital syndrome: an acquired transition condition of generalized risk. N Engl J Med. 2013;368:100-102.
2. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793.

Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.¹

Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).²

Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.¹ Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.

For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.

Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”

References

1. Krumholz HM. Post-hospital syndrome: an acquired transition condition of generalized risk. N Engl J Med. 2013;368:100-102.
2. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793.

Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.¹

Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).²

Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.¹ Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.

For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.

Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”

References

1. Krumholz HM. Post-hospital syndrome: an acquired transition condition of generalized risk. N Engl J Med. 2013;368:100-102.
2. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793.

A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).

Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.¹ DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.

With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.

“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”

Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.

Reference

1. Wascome E, McDonough J, McLemore M, Slataper R. Computerized patient assignment (CPA) saves time and improves coordination of care [abstract]. J Hosp Med. 2012;7(Suppl 2):S106-107.

Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).

Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.¹ DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.

With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.

“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”

Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.

Reference

1. Wascome E, McDonough J, McLemore M, Slataper R. Computerized patient assignment (CPA) saves time and improves coordination of care [abstract]. J Hosp Med. 2012;7(Suppl 2):S106-107.

Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).

Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.¹ DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.

With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.

“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”

Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.

Reference

1. Wascome E, McDonough J, McLemore M, Slataper R. Computerized patient assignment (CPA) saves time and improves coordination of care [abstract]. J Hosp Med. 2012;7(Suppl 2):S106-107.

For the past 2 weeks I have been on call overnight and to put it lightly, it has been brutal. Fellow call, unlike resident call, can be taken from home, but some nights it seems almost as though it would be easier to just stay at the hospital. My pager typically starts going off at 5:01 pm and does not stop until sometime after midnight. Nightly, I have been averaging a record number of admissions, consults, outpatient calls, and enough inpatient issues to keep me awake stalking labs and vitals until the early morning, just in time to get the critical lab calls from nursing.

*Click on the link to the left of this introduction for a PDF of the full article.

For the past 2 weeks I have been on call overnight and to put it lightly, it has been brutal. Fellow call, unlike resident call, can be taken from home, but some nights it seems almost as though it would be easier to just stay at the hospital. My pager typically starts going off at 5:01 pm and does not stop until sometime after midnight. Nightly, I have been averaging a record number of admissions, consults, outpatient calls, and enough inpatient issues to keep me awake stalking labs and vitals until the early morning, just in time to get the critical lab calls from nursing.

*Click on the link to the left of this introduction for a PDF of the full article.

For the past 2 weeks I have been on call overnight and to put it lightly, it has been brutal. Fellow call, unlike resident call, can be taken from home, but some nights it seems almost as though it would be easier to just stay at the hospital. My pager typically starts going off at 5:01 pm and does not stop until sometime after midnight. Nightly, I have been averaging a record number of admissions, consults, outpatient calls, and enough inpatient issues to keep me awake stalking labs and vitals until the early morning, just in time to get the critical lab calls from nursing.

*Click on the link to the left of this introduction for a PDF of the full article.

Background Within community oncology practices, the regimens used for treatment of postmenopausal women with human epidermal growth factor receptor 2- and hormone receptor-positive metastatic breast cancer (MBC) may vary.

Objective A retrospective observational study was conducted to examine treatment patterns in HER2-/HR-positive patients initiating first-line treatment in a community oncology setting.

Methods Using US Oncology’s iKnowMed electronic health records (EHRs), postmenopausal HER2-/HR-positive patients who had been newly diagnosed with MBC between January 1, 2007 and June 30, 2010 were identified and stratified by visceral crisis.

Results We identified 347 postmenopausal HER2-/HR-positive patients, of whom 258 (74%) did not have evidence of visceral crisis. Chemotherapy plus targeted plus hormone therapy was the most frequently used treatment strategy (33%). Trastuzumab was the most frequently used HER2-targeted therapy (77% and 66% with and without visceral crisis, respectively); followed by lapatinib. Paclitaxel (24%, nonvisceral; 39% visceral) and letrozole (26%, nonvisceral; 28% visceral) were the most frequently used chemotherapy and endocrine therapies, respectively. Over time, trastuzumab use decreased whereas lapatinib use increased.

Limitation The heterogeneity in the regimens prescribed precluded large sample sizes for robust statistical analyses to link specific therapeutic combinations with outcomes.

Conclusion Community oncologists use a variety of treatments in postmenopausal women with HER2-/HR-positive MBC. Although a combination of chemotherapy, targeted HER2 therapy, and hormone therapy were the most common first-line therapies used, contrary to treatment guidelines, a large proportion of patients received no chemotherapy in the first-line setting.

*Click on the link to the left for a PDF of the full article.

Background Within community oncology practices, the regimens used for treatment of postmenopausal women with human epidermal growth factor receptor 2- and hormone receptor-positive metastatic breast cancer (MBC) may vary.

Objective A retrospective observational study was conducted to examine treatment patterns in HER2-/HR-positive patients initiating first-line treatment in a community oncology setting.

Methods Using US Oncology’s iKnowMed electronic health records (EHRs), postmenopausal HER2-/HR-positive patients who had been newly diagnosed with MBC between January 1, 2007 and June 30, 2010 were identified and stratified by visceral crisis.

Results We identified 347 postmenopausal HER2-/HR-positive patients, of whom 258 (74%) did not have evidence of visceral crisis. Chemotherapy plus targeted plus hormone therapy was the most frequently used treatment strategy (33%). Trastuzumab was the most frequently used HER2-targeted therapy (77% and 66% with and without visceral crisis, respectively); followed by lapatinib. Paclitaxel (24%, nonvisceral; 39% visceral) and letrozole (26%, nonvisceral; 28% visceral) were the most frequently used chemotherapy and endocrine therapies, respectively. Over time, trastuzumab use decreased whereas lapatinib use increased.

Limitation The heterogeneity in the regimens prescribed precluded large sample sizes for robust statistical analyses to link specific therapeutic combinations with outcomes.

Conclusion Community oncologists use a variety of treatments in postmenopausal women with HER2-/HR-positive MBC. Although a combination of chemotherapy, targeted HER2 therapy, and hormone therapy were the most common first-line therapies used, contrary to treatment guidelines, a large proportion of patients received no chemotherapy in the first-line setting.

*Click on the link to the left for a PDF of the full article.

Background Within community oncology practices, the regimens used for treatment of postmenopausal women with human epidermal growth factor receptor 2- and hormone receptor-positive metastatic breast cancer (MBC) may vary.

Objective A retrospective observational study was conducted to examine treatment patterns in HER2-/HR-positive patients initiating first-line treatment in a community oncology setting.

Methods Using US Oncology’s iKnowMed electronic health records (EHRs), postmenopausal HER2-/HR-positive patients who had been newly diagnosed with MBC between January 1, 2007 and June 30, 2010 were identified and stratified by visceral crisis.

Results We identified 347 postmenopausal HER2-/HR-positive patients, of whom 258 (74%) did not have evidence of visceral crisis. Chemotherapy plus targeted plus hormone therapy was the most frequently used treatment strategy (33%). Trastuzumab was the most frequently used HER2-targeted therapy (77% and 66% with and without visceral crisis, respectively); followed by lapatinib. Paclitaxel (24%, nonvisceral; 39% visceral) and letrozole (26%, nonvisceral; 28% visceral) were the most frequently used chemotherapy and endocrine therapies, respectively. Over time, trastuzumab use decreased whereas lapatinib use increased.

Limitation The heterogeneity in the regimens prescribed precluded large sample sizes for robust statistical analyses to link specific therapeutic combinations with outcomes.

Conclusion Community oncologists use a variety of treatments in postmenopausal women with HER2-/HR-positive MBC. Although a combination of chemotherapy, targeted HER2 therapy, and hormone therapy were the most common first-line therapies used, contrary to treatment guidelines, a large proportion of patients received no chemotherapy in the first-line setting.

*Click on the link to the left for a PDF of the full article.

To the Editor: In her recent overview of emergency contraception (November 2012),¹ Dr. Batur wrote that emergency contraception with levonorgestrel (Plan B One-Step) or combined estrogen-progestin-based methods does not cause abortion, noting that it is “unlikely to affect the ability of the embryo to attach to the endometrium.”¹ We disagree. We consider any interruption of human development after fertilization to be abortion (ie, abortifacient).

Recently, Noé et al² found that levonorgestrel was 100% effective in stopping clinical pregnancy when given 1 or 2 days before ovulation. However, previously, Croxatto et al³ noted (through ultrasonography) that levonorgestrel allowed ovulation 88% of the time when given 1 or 2 days before ovulation. Since levonorgestrel’s efficacy is significantly higher than its ability to inhibit ovulation on these days, another mechanism of action must be operant when ovulation does occur, that is, the other 88% of the time. A non-contraceptive action is the most likely explanation by default since the other main effect (ie, thickening of cervical mucus) likely plays little role if levonorgestrel is taken several hours after sexual activity.

Dr. Batur states that levonorgestrel is not an abortion pill because it serves “to enhance the progesterone effect”¹ on the endometrium; however, it causes menstrual bleeding in about 15% of women taking it within 7 days.⁴ In addition, Kesserü et al⁵ noted that the intrauterine pH rose to more than 9 when a low dose was given. This is a 10-fold increase in alkalinity above the normal uterine pH. The pH within the fallopian tubes was not measured, but if a similar rise in pH occurred, it could easily explain how early embryos might die from levonorgestrel.

The medical literature cited above is consistent with the manufacturer’s claim that levonorgestrel “may inhibit implantation,” ⁶ and with the American Congress of Obstetricians and Gynecologists’ statement that “prevention of implantation may be a secondary mechanism of action.”⁷ Physicians and patients should be aware of this important ethical and clinical point.

To the Editor: In her recent overview of emergency contraception (November 2012),¹ Dr. Batur wrote that emergency contraception with levonorgestrel (Plan B One-Step) or combined estrogen-progestin-based methods does not cause abortion, noting that it is “unlikely to affect the ability of the embryo to attach to the endometrium.”¹ We disagree. We consider any interruption of human development after fertilization to be abortion (ie, abortifacient).

Recently, Noé et al² found that levonorgestrel was 100% effective in stopping clinical pregnancy when given 1 or 2 days before ovulation. However, previously, Croxatto et al³ noted (through ultrasonography) that levonorgestrel allowed ovulation 88% of the time when given 1 or 2 days before ovulation. Since levonorgestrel’s efficacy is significantly higher than its ability to inhibit ovulation on these days, another mechanism of action must be operant when ovulation does occur, that is, the other 88% of the time. A non-contraceptive action is the most likely explanation by default since the other main effect (ie, thickening of cervical mucus) likely plays little role if levonorgestrel is taken several hours after sexual activity.

Dr. Batur states that levonorgestrel is not an abortion pill because it serves “to enhance the progesterone effect”¹ on the endometrium; however, it causes menstrual bleeding in about 15% of women taking it within 7 days.⁴ In addition, Kesserü et al⁵ noted that the intrauterine pH rose to more than 9 when a low dose was given. This is a 10-fold increase in alkalinity above the normal uterine pH. The pH within the fallopian tubes was not measured, but if a similar rise in pH occurred, it could easily explain how early embryos might die from levonorgestrel.

The medical literature cited above is consistent with the manufacturer’s claim that levonorgestrel “may inhibit implantation,” ⁶ and with the American Congress of Obstetricians and Gynecologists’ statement that “prevention of implantation may be a secondary mechanism of action.”⁷ Physicians and patients should be aware of this important ethical and clinical point.

To the Editor: In her recent overview of emergency contraception (November 2012),¹ Dr. Batur wrote that emergency contraception with levonorgestrel (Plan B One-Step) or combined estrogen-progestin-based methods does not cause abortion, noting that it is “unlikely to affect the ability of the embryo to attach to the endometrium.”¹ We disagree. We consider any interruption of human development after fertilization to be abortion (ie, abortifacient).

Recently, Noé et al² found that levonorgestrel was 100% effective in stopping clinical pregnancy when given 1 or 2 days before ovulation. However, previously, Croxatto et al³ noted (through ultrasonography) that levonorgestrel allowed ovulation 88% of the time when given 1 or 2 days before ovulation. Since levonorgestrel’s efficacy is significantly higher than its ability to inhibit ovulation on these days, another mechanism of action must be operant when ovulation does occur, that is, the other 88% of the time. A non-contraceptive action is the most likely explanation by default since the other main effect (ie, thickening of cervical mucus) likely plays little role if levonorgestrel is taken several hours after sexual activity.

Dr. Batur states that levonorgestrel is not an abortion pill because it serves “to enhance the progesterone effect”¹ on the endometrium; however, it causes menstrual bleeding in about 15% of women taking it within 7 days.⁴ In addition, Kesserü et al⁵ noted that the intrauterine pH rose to more than 9 when a low dose was given. This is a 10-fold increase in alkalinity above the normal uterine pH. The pH within the fallopian tubes was not measured, but if a similar rise in pH occurred, it could easily explain how early embryos might die from levonorgestrel.

The medical literature cited above is consistent with the manufacturer’s claim that levonorgestrel “may inhibit implantation,” ⁶ and with the American Congress of Obstetricians and Gynecologists’ statement that “prevention of implantation may be a secondary mechanism of action.”⁷ Physicians and patients should be aware of this important ethical and clinical point.