Most would agree that "we are seeing more thrombosis over time" in children over the past decade, and although we don't know why, it is likely due to multifactorial causes, said Leslie Raffini, MD, MSCE, director of the Hemostasis and Thrombosis Center at Children's Hospital of Philadelphia, in a session on Monday at HM12.

Central venous catheters remain a significant risk factor for venous thromboembolism (VTE) and our knowledge of inherited risk factors has expanded in recent years. While it is likely that inherited risk factors increase the risk of thrombosis in children, the question of testing has engendered debate, due in large part to the lack of clear benefit of that information in the majority of situations.

"The decision to test should be made on an individual basis, after counseling," said Dr. Raffini. "Results should be interpreted by an experienced physician with adolescent females most likely to benefit from the testing. There are no recommendations for what to do with pediatric patients" despite the fact that this is an important cause of morbidity in high-risk patients.

Dr. Raffini describes efforts at Children's Hospital of Philadelphia that led to a VTE prophylaxis guideline. Successful implementation of the guideline required significant multidisciplinary collaboration, and an analysis of outcomes is underway.

Takeaways

• The decision to test for inherited risk factors should be individualized.
• Adolescent females are most likely to benefit from testing for inherited risk factors.
• Implementation of guidelines requires intentional multidisciplinary collaboration.

Most would agree that "we are seeing more thrombosis over time" in children over the past decade, and although we don't know why, it is likely due to multifactorial causes, said Leslie Raffini, MD, MSCE, director of the Hemostasis and Thrombosis Center at Children's Hospital of Philadelphia, in a session on Monday at HM12.

Central venous catheters remain a significant risk factor for venous thromboembolism (VTE) and our knowledge of inherited risk factors has expanded in recent years. While it is likely that inherited risk factors increase the risk of thrombosis in children, the question of testing has engendered debate, due in large part to the lack of clear benefit of that information in the majority of situations.

"The decision to test should be made on an individual basis, after counseling," said Dr. Raffini. "Results should be interpreted by an experienced physician with adolescent females most likely to benefit from the testing. There are no recommendations for what to do with pediatric patients" despite the fact that this is an important cause of morbidity in high-risk patients.

Dr. Raffini describes efforts at Children's Hospital of Philadelphia that led to a VTE prophylaxis guideline. Successful implementation of the guideline required significant multidisciplinary collaboration, and an analysis of outcomes is underway.

Takeaways

• The decision to test for inherited risk factors should be individualized.
• Adolescent females are most likely to benefit from testing for inherited risk factors.
• Implementation of guidelines requires intentional multidisciplinary collaboration.

Most would agree that "we are seeing more thrombosis over time" in children over the past decade, and although we don't know why, it is likely due to multifactorial causes, said Leslie Raffini, MD, MSCE, director of the Hemostasis and Thrombosis Center at Children's Hospital of Philadelphia, in a session on Monday at HM12.

Central venous catheters remain a significant risk factor for venous thromboembolism (VTE) and our knowledge of inherited risk factors has expanded in recent years. While it is likely that inherited risk factors increase the risk of thrombosis in children, the question of testing has engendered debate, due in large part to the lack of clear benefit of that information in the majority of situations.

"The decision to test should be made on an individual basis, after counseling," said Dr. Raffini. "Results should be interpreted by an experienced physician with adolescent females most likely to benefit from the testing. There are no recommendations for what to do with pediatric patients" despite the fact that this is an important cause of morbidity in high-risk patients.

Dr. Raffini describes efforts at Children's Hospital of Philadelphia that led to a VTE prophylaxis guideline. Successful implementation of the guideline required significant multidisciplinary collaboration, and an analysis of outcomes is underway.

Takeaways

• The decision to test for inherited risk factors should be individualized.
• Adolescent females are most likely to benefit from testing for inherited risk factors.
• Implementation of guidelines requires intentional multidisciplinary collaboration.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

A panel of diverse hospital systems shared successes and challenges with SHM's Project BOOST program, which aims to reduce readmissions for older adults. Although each initiative is (purposefully) tailored to the site, each share common themes, including the use of multidisciplinary teams, discharge process redesign, the use of teach back, and the use of follow up phone calls.

Key Takeaways:

• BOOST has been widely successful in improving the discharge process in a variety of hospital settings;
• Mentored implementation is a critical factor to it’s success.

Dr. Scheurer is physician editor of The Hospitalist

A panel of diverse hospital systems shared successes and challenges with SHM's Project BOOST program, which aims to reduce readmissions for older adults. Although each initiative is (purposefully) tailored to the site, each share common themes, including the use of multidisciplinary teams, discharge process redesign, the use of teach back, and the use of follow up phone calls.

Key Takeaways:

• BOOST has been widely successful in improving the discharge process in a variety of hospital settings;
• Mentored implementation is a critical factor to it’s success.

Dr. Scheurer is physician editor of The Hospitalist

A panel of diverse hospital systems shared successes and challenges with SHM's Project BOOST program, which aims to reduce readmissions for older adults. Although each initiative is (purposefully) tailored to the site, each share common themes, including the use of multidisciplinary teams, discharge process redesign, the use of teach back, and the use of follow up phone calls.

Key Takeaways:

• BOOST has been widely successful in improving the discharge process in a variety of hospital settings;
• Mentored implementation is a critical factor to it’s success.

Dr. Scheurer is physician editor of The Hospitalist

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.

As part of the Affordable Care Act, the value-based purchasing program (VBP) is being rolled out this year. Beginning in October, VBP will put hospitals at financial risk for a defined set of clinical and patient satisfaction metrics. Because of the significant impact that this will have on hospitals and HM, SHM had a pre-course focused on this topic at HM12.

Pat Torscon and Joe Miller led the pre-course, which focused on VBP's key components. Through a series of vignettes and studies, the faculty provided nearly 100 attendess a better understanding of the impact.

Key Takeaways

1. VBP is budget neutral. Some Hospitals will receive bonuses, some will not. This will depend on where hospitals fall in the performance score. To receive a bonus, a hospital will have to exceed the 50% threshold. If below, then no opportunity for performance bonus. The model is based on a floor, a threshold (50%), and benchmark, which is presently a bell-shaped curve.

2. The performance score will be 70% clinical process domain and 30% patient experience domain. Hospitalists will have a major role in the perfromance measures around AMI, CHF, pneumonia, SCIP, and patient experience.

3. Hospitalists will need to understand the data and where it comes from. When you combine VBP, Inpatient Quality Reporting, readmissions, hospital-acquired conditions, and meaningful use, the actual amount of payment at risk is 7%. With most hospital profit margins around 1-3% this amount will be significant. Of those hospitals that have been studied, 10% in high performance, and 74% were inconsistent performance across four clinical measures.

4. Concurrent patient management will be important. Hospitalists will become the drivers and champions of this. To move either your HCAHPS score or Press Ganey performance scores will take time. It is important to convey that to the C-suite. An example of the impact of VBP for a 146-bed hospital over five years could be more than $5 million at stake; a 541-bed hospital would be $40 million.

As part of the Affordable Care Act, the value-based purchasing program (VBP) is being rolled out this year. Beginning in October, VBP will put hospitals at financial risk for a defined set of clinical and patient satisfaction metrics. Because of the significant impact that this will have on hospitals and HM, SHM had a pre-course focused on this topic at HM12.

Pat Torscon and Joe Miller led the pre-course, which focused on VBP's key components. Through a series of vignettes and studies, the faculty provided nearly 100 attendess a better understanding of the impact.

Key Takeaways

1. VBP is budget neutral. Some Hospitals will receive bonuses, some will not. This will depend on where hospitals fall in the performance score. To receive a bonus, a hospital will have to exceed the 50% threshold. If below, then no opportunity for performance bonus. The model is based on a floor, a threshold (50%), and benchmark, which is presently a bell-shaped curve.

2. The performance score will be 70% clinical process domain and 30% patient experience domain. Hospitalists will have a major role in the perfromance measures around AMI, CHF, pneumonia, SCIP, and patient experience.

3. Hospitalists will need to understand the data and where it comes from. When you combine VBP, Inpatient Quality Reporting, readmissions, hospital-acquired conditions, and meaningful use, the actual amount of payment at risk is 7%. With most hospital profit margins around 1-3% this amount will be significant. Of those hospitals that have been studied, 10% in high performance, and 74% were inconsistent performance across four clinical measures.

4. Concurrent patient management will be important. Hospitalists will become the drivers and champions of this. To move either your HCAHPS score or Press Ganey performance scores will take time. It is important to convey that to the C-suite. An example of the impact of VBP for a 146-bed hospital over five years could be more than $5 million at stake; a 541-bed hospital would be $40 million.

As part of the Affordable Care Act, the value-based purchasing program (VBP) is being rolled out this year. Beginning in October, VBP will put hospitals at financial risk for a defined set of clinical and patient satisfaction metrics. Because of the significant impact that this will have on hospitals and HM, SHM had a pre-course focused on this topic at HM12.

Pat Torscon and Joe Miller led the pre-course, which focused on VBP's key components. Through a series of vignettes and studies, the faculty provided nearly 100 attendess a better understanding of the impact.

Key Takeaways

1. VBP is budget neutral. Some Hospitals will receive bonuses, some will not. This will depend on where hospitals fall in the performance score. To receive a bonus, a hospital will have to exceed the 50% threshold. If below, then no opportunity for performance bonus. The model is based on a floor, a threshold (50%), and benchmark, which is presently a bell-shaped curve.

2. The performance score will be 70% clinical process domain and 30% patient experience domain. Hospitalists will have a major role in the perfromance measures around AMI, CHF, pneumonia, SCIP, and patient experience.

3. Hospitalists will need to understand the data and where it comes from. When you combine VBP, Inpatient Quality Reporting, readmissions, hospital-acquired conditions, and meaningful use, the actual amount of payment at risk is 7%. With most hospital profit margins around 1-3% this amount will be significant. Of those hospitals that have been studied, 10% in high performance, and 74% were inconsistent performance across four clinical measures.

4. Concurrent patient management will be important. Hospitalists will become the drivers and champions of this. To move either your HCAHPS score or Press Ganey performance scores will take time. It is important to convey that to the C-suite. An example of the impact of VBP for a 146-bed hospital over five years could be more than $5 million at stake; a 541-bed hospital would be $40 million.

HM12 formally kicked off for thousands of hospitalists on Monday morning with two plenary addresses that couldn't have been more different.

First up, Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), provided a rapid-fire insight into the breadth of CMS and asked hospitalists to consider the government behemoth as a partner in systems change. Political analyst Norman Ornstein, PhD, MA, then presented a global view of the dysfunction racking the political system (once he finished an opening monologue of political jibes that would have made late-night writers proud).

But while the plenary perspectives differed in theme, they converged on implication: The next few years will be a period of change for healthcare and HM.

"The fact is if we had a political system operating on all cylinders at this point, if we had a law put into place and then assurances that it would continue, and that everybody would be making a good faith effort to make it work, it would still hold years of tumult ahead as we try to figure out how we can change cultures, change behaviors, and still along the way provide quality care at a price that is going to be acceptable enough in the system to make it work,” Ornstein said.

Dr. Conway summed it up this way: “better health, better care, and lower cost.”

Dr. Conway, who maintains a presence in the clinical world by working unpaid weekend shifts at Children's National Medical Center in Washington, D.C., says that while individual hospitalists might feel their contribution is too small to translate to systems change, they are wrong. Change, he says, begins at the local level.

"My challenge to you is: Please don't sit on the sidelines," Dr. Conway said. "Please be actively engaged in your local system in creating this change."

HM12 formally kicked off for thousands of hospitalists on Monday morning with two plenary addresses that couldn't have been more different.

First up, Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), provided a rapid-fire insight into the breadth of CMS and asked hospitalists to consider the government behemoth as a partner in systems change. Political analyst Norman Ornstein, PhD, MA, then presented a global view of the dysfunction racking the political system (once he finished an opening monologue of political jibes that would have made late-night writers proud).

But while the plenary perspectives differed in theme, they converged on implication: The next few years will be a period of change for healthcare and HM.

"The fact is if we had a political system operating on all cylinders at this point, if we had a law put into place and then assurances that it would continue, and that everybody would be making a good faith effort to make it work, it would still hold years of tumult ahead as we try to figure out how we can change cultures, change behaviors, and still along the way provide quality care at a price that is going to be acceptable enough in the system to make it work,” Ornstein said.

Dr. Conway summed it up this way: “better health, better care, and lower cost.”

Dr. Conway, who maintains a presence in the clinical world by working unpaid weekend shifts at Children's National Medical Center in Washington, D.C., says that while individual hospitalists might feel their contribution is too small to translate to systems change, they are wrong. Change, he says, begins at the local level.

"My challenge to you is: Please don't sit on the sidelines," Dr. Conway said. "Please be actively engaged in your local system in creating this change."

HM12 formally kicked off for thousands of hospitalists on Monday morning with two plenary addresses that couldn't have been more different.

First up, Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), provided a rapid-fire insight into the breadth of CMS and asked hospitalists to consider the government behemoth as a partner in systems change. Political analyst Norman Ornstein, PhD, MA, then presented a global view of the dysfunction racking the political system (once he finished an opening monologue of political jibes that would have made late-night writers proud).

But while the plenary perspectives differed in theme, they converged on implication: The next few years will be a period of change for healthcare and HM.

"The fact is if we had a political system operating on all cylinders at this point, if we had a law put into place and then assurances that it would continue, and that everybody would be making a good faith effort to make it work, it would still hold years of tumult ahead as we try to figure out how we can change cultures, change behaviors, and still along the way provide quality care at a price that is going to be acceptable enough in the system to make it work,” Ornstein said.

Dr. Conway summed it up this way: “better health, better care, and lower cost.”

Dr. Conway, who maintains a presence in the clinical world by working unpaid weekend shifts at Children's National Medical Center in Washington, D.C., says that while individual hospitalists might feel their contribution is too small to translate to systems change, they are wrong. Change, he says, begins at the local level.

"My challenge to you is: Please don't sit on the sidelines," Dr. Conway said. "Please be actively engaged in your local system in creating this change."

Hospitalist scheduling is one of the tools in the toolbox of hospital medicine practices.

“And like any other tool, it can be used for good or ill, depending on the skills of the operator,” said Greg Harlan, MD, MPH, director of medical affairs for IPC The Hospitalist Company, Monday at HM12 in San Diego.

Dr. Harlan encouraged hospitalists to make their schedule a target for systematic process improvement, using quality improvement techniques such as survey/plan/implement/evaluate improvement cycles. Work with various constituencies to clarify their concerns and identify up front the appropriate metrics to track (e.g., length of stay, readmissions, and morning discharges). Dr. Harlan also emphasized the value of hospitalist-led multidisciplinary daily rounding on patients, which can improve communication and efficiency.

There are a variety of scheduling models, including seven days on/seven days off, weekday/weekend, admitters and rounders, zone scheduling, and the CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) model, said co-presenter Shalini Chandra, MD, assistant professor of medicine at Johns Hopkins University. “The key is to find your best fit,” she noted, which may be a hybrid of different approaches that reflects the hospital, the patient population, and the needs of the hospitalist group by considering its members’ stages of life.

Responding to surges in patient census, honoring group members' needs for flexibility in scheduling, may present competing dilemmas for the schedule. An electronic scheduling software could be a helpful adjunct, presenters said.

Wayne DeMott, MD, of Victoria Hospitalist Physicians, Inc., in Victoria, British Columbia, said he came to the session to learn how American hospitalists handle the usual problems of managing schedules.

“I’m pretty convinced that there isn't a Holy Grail of scheduling,” he said, adding that the concerns sound similar on both sides of the border. He also said American hospitals have managed to bring down lengths of hospital stays far beyond their Canadian counterparts.

Hospitalist scheduling is one of the tools in the toolbox of hospital medicine practices.

“And like any other tool, it can be used for good or ill, depending on the skills of the operator,” said Greg Harlan, MD, MPH, director of medical affairs for IPC The Hospitalist Company, Monday at HM12 in San Diego.

Dr. Harlan encouraged hospitalists to make their schedule a target for systematic process improvement, using quality improvement techniques such as survey/plan/implement/evaluate improvement cycles. Work with various constituencies to clarify their concerns and identify up front the appropriate metrics to track (e.g., length of stay, readmissions, and morning discharges). Dr. Harlan also emphasized the value of hospitalist-led multidisciplinary daily rounding on patients, which can improve communication and efficiency.

There are a variety of scheduling models, including seven days on/seven days off, weekday/weekend, admitters and rounders, zone scheduling, and the CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) model, said co-presenter Shalini Chandra, MD, assistant professor of medicine at Johns Hopkins University. “The key is to find your best fit,” she noted, which may be a hybrid of different approaches that reflects the hospital, the patient population, and the needs of the hospitalist group by considering its members’ stages of life.

Responding to surges in patient census, honoring group members' needs for flexibility in scheduling, may present competing dilemmas for the schedule. An electronic scheduling software could be a helpful adjunct, presenters said.

Wayne DeMott, MD, of Victoria Hospitalist Physicians, Inc., in Victoria, British Columbia, said he came to the session to learn how American hospitalists handle the usual problems of managing schedules.

“I’m pretty convinced that there isn't a Holy Grail of scheduling,” he said, adding that the concerns sound similar on both sides of the border. He also said American hospitals have managed to bring down lengths of hospital stays far beyond their Canadian counterparts.

Hospitalist scheduling is one of the tools in the toolbox of hospital medicine practices.

“And like any other tool, it can be used for good or ill, depending on the skills of the operator,” said Greg Harlan, MD, MPH, director of medical affairs for IPC The Hospitalist Company, Monday at HM12 in San Diego.

Dr. Harlan encouraged hospitalists to make their schedule a target for systematic process improvement, using quality improvement techniques such as survey/plan/implement/evaluate improvement cycles. Work with various constituencies to clarify their concerns and identify up front the appropriate metrics to track (e.g., length of stay, readmissions, and morning discharges). Dr. Harlan also emphasized the value of hospitalist-led multidisciplinary daily rounding on patients, which can improve communication and efficiency.

There are a variety of scheduling models, including seven days on/seven days off, weekday/weekend, admitters and rounders, zone scheduling, and the CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) model, said co-presenter Shalini Chandra, MD, assistant professor of medicine at Johns Hopkins University. “The key is to find your best fit,” she noted, which may be a hybrid of different approaches that reflects the hospital, the patient population, and the needs of the hospitalist group by considering its members’ stages of life.

Responding to surges in patient census, honoring group members' needs for flexibility in scheduling, may present competing dilemmas for the schedule. An electronic scheduling software could be a helpful adjunct, presenters said.

Wayne DeMott, MD, of Victoria Hospitalist Physicians, Inc., in Victoria, British Columbia, said he came to the session to learn how American hospitalists handle the usual problems of managing schedules.

“I’m pretty convinced that there isn't a Holy Grail of scheduling,” he said, adding that the concerns sound similar on both sides of the border. He also said American hospitals have managed to bring down lengths of hospital stays far beyond their Canadian counterparts.

"Hopefully there will be a test available to physicians for diagnosing KD in the next 5 years," said Adriana Tremoulet, MD, MAS, who is the Associate Director of the Kawasaki Disease Research Center at Rady Children's Hospital/UC San Diego. Research into biomarkers looks promising and there is even some work underway to develop an app to help with the diagnostic algorithm for atypical cases, shared Dr. Tremoulet.

While many of the ways in which we make the diagnosis of KD have remained the same over the years, with little insight into the etiology, beware of clusters of certain presentations, to include shock, or "Kawashocki" Disease.

Treatment with IVIG remains first-line therapy, but there is a need to do more research into effective treatment for high risk populations—IVIG-resistant children. "The future of this disease is how we will treat all children," Dr. Tremoulet said as she described the research design challenges for children that have already failed therapy. Controlled trials are underway to evaluate new treatments in this population.

Exciting collaborations with climate scientists have produced potential leads into associations with tropospheric wind patterns. "We cannot do this work alone," and physicians on the West Coast are urged to participate in an ongoing collaborative related to this research.

Key Takeaways:

• For unclear reasons, presentations of KD continue to cluster; climate may play a role;
• Use IVIG for children that present with "Kawashocki" Disease;
• Research may soon provide us with diagnostic biomarkers as well as treatments for high-risk children; and
• Contact Olivia Fabri, Research Coordinator, to receive more information related to the West Coast KD Epidemiology Consortium (WIND study).

"Hopefully there will be a test available to physicians for diagnosing KD in the next 5 years," said Adriana Tremoulet, MD, MAS, who is the Associate Director of the Kawasaki Disease Research Center at Rady Children's Hospital/UC San Diego. Research into biomarkers looks promising and there is even some work underway to develop an app to help with the diagnostic algorithm for atypical cases, shared Dr. Tremoulet.

While many of the ways in which we make the diagnosis of KD have remained the same over the years, with little insight into the etiology, beware of clusters of certain presentations, to include shock, or "Kawashocki" Disease.

Treatment with IVIG remains first-line therapy, but there is a need to do more research into effective treatment for high risk populations—IVIG-resistant children. "The future of this disease is how we will treat all children," Dr. Tremoulet said as she described the research design challenges for children that have already failed therapy. Controlled trials are underway to evaluate new treatments in this population.

Exciting collaborations with climate scientists have produced potential leads into associations with tropospheric wind patterns. "We cannot do this work alone," and physicians on the West Coast are urged to participate in an ongoing collaborative related to this research.

Key Takeaways:

• For unclear reasons, presentations of KD continue to cluster; climate may play a role;
• Use IVIG for children that present with "Kawashocki" Disease;
• Research may soon provide us with diagnostic biomarkers as well as treatments for high-risk children; and
• Contact Olivia Fabri, Research Coordinator, to receive more information related to the West Coast KD Epidemiology Consortium (WIND study).

"Hopefully there will be a test available to physicians for diagnosing KD in the next 5 years," said Adriana Tremoulet, MD, MAS, who is the Associate Director of the Kawasaki Disease Research Center at Rady Children's Hospital/UC San Diego. Research into biomarkers looks promising and there is even some work underway to develop an app to help with the diagnostic algorithm for atypical cases, shared Dr. Tremoulet.

While many of the ways in which we make the diagnosis of KD have remained the same over the years, with little insight into the etiology, beware of clusters of certain presentations, to include shock, or "Kawashocki" Disease.

Treatment with IVIG remains first-line therapy, but there is a need to do more research into effective treatment for high risk populations—IVIG-resistant children. "The future of this disease is how we will treat all children," Dr. Tremoulet said as she described the research design challenges for children that have already failed therapy. Controlled trials are underway to evaluate new treatments in this population.

Exciting collaborations with climate scientists have produced potential leads into associations with tropospheric wind patterns. "We cannot do this work alone," and physicians on the West Coast are urged to participate in an ongoing collaborative related to this research.

Key Takeaways:

• For unclear reasons, presentations of KD continue to cluster; climate may play a role;
• Use IVIG for children that present with "Kawashocki" Disease;
• Research may soon provide us with diagnostic biomarkers as well as treatments for high-risk children; and
• Contact Olivia Fabri, Research Coordinator, to receive more information related to the West Coast KD Epidemiology Consortium (WIND study).

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.