Editorial

Hospitalists who teach in the clinical environment face challenges that include increased workload,[1] perception among trainees that there is less time to teach,[2] and competition with electronic devices for teaching engagement.[3, 4] In view of these and other challenges, we believe there is potentially much to gain from considering and adapting educational techniques that have been successful in nonhospital and even nonmedical domains. Innovative teaching methods include those designed for the grade‐school classroom (Courage to Teach,[5] Teaching With Love and Logic[6]), and the business world (Teaching Smart People How to Learn,[7] The Back of the Napkin[8]), among other nonmedical professions. Within medicine, we can also re‐examine strategies long utilized in the ambulatory setting. Pascoe and colleagues offer an important example of this in their review of one‐minute preceptor (OMP) and SNAPPS, techniques developed by our colleagues in the outpatient setting but with great potential for framing discussion of clinical reasoning in the inpatient space.[9]

Applying OMP and SNAPPS to inpatient teaching presents some challenges but also genuine opportunities not found in traditional outpatient teaching. As noted by the authors, unlike the solitary learner typical of the outpatient setting, in the inpatient setting the attending is more commonly working with a group of learners of multiple levels and sometimes multiple disciplines. Furthermore, the supervising resident typical of inpatient teams is a learner who inhabits the roles of both trainee and teacher. One can imagine that if OMP and SNAPPs are applied with absolute fidelity to the inpatient setting, without reflection on venue, the teaching encounter might be overly focused on the presenting learner, leaving the rest of the team unattended to, disengaged, and not benefitting from the models. Therefore, attention to group engagement in the process is necessary for successful adaptation. Both models have the potential to help organize the group dynamic during rounds to promote broad participation. The authors describe some examples of how to engage various group members in different steps. It is worth highlighting a few key themes that enable successful use of these models in the inpatient setting.

One key theme is to teach the model to the supervising resident at the beginning of the rotation and agree, before rounds, how the attending and resident will interact as coleaders of the discussion. Because these models offer a stepwise approach to going through a case with a learner, they have the potential to demystify the teaching process, offering an accessible framework for supervising residents to learn teaching both by practicing and by comprehending what their attending is doing to lead a team through a case discussion. With attending support, the supervising resident can be encouraged to manage the team discussion, leading the team using either approach. It can be helpful to touch base briefly before rounds each day to define the teaching roles, giving the resident progressively more responsibility leading the discussion as the rotation progresses.

Another key theme is to use graduated participation. As the authors note, the group must be engaged in the discussion, and the example scenarios illustrate each step of the models being applied to the group. To ensure that the entire group remains eager to partake, the leader must maintain a nonthreatening teaching atmosphere, organizing participation in a way that does not shame learners or undermine the roles people inhabit. To this end, it can be helpful to direct questions to particular members or levels of the group at a time. When expanding participation around a specific question or concept, always work from junior members to senior members, never imposing the reverse. This principle is clearly not exclusive to using these models, but is requisite to successful adaptation of these traditionally dyadic models, in which there is no particular attention to group dynamics within the framework.

A third key theme is to utilize the unique expertise of the other health professionals on the team in steps 4, 5, and 6 of SNAPPS and step 3 of OMP. In step 4 and 5 of SNAPPS, when the teaching attending introduces the team to the model, it is important to encourage them to probe not just the teacher but other disciplines on the team for input. In the inpatient setting, these steps provide an organized point in the discussion in which to involve the other members of the professional team, modeling collaborative interdisciplinary practice.

As Pascoe et al. point out, there are limited studies of OMP and SNAPPS as teaching models in the inpatient environment. This should stimulate academic hospitalists with interest in medical education research to consider how these models might be studied. For example, in comparison to traditional inpatient teaching rounds, do these approaches provide equivalent content coverage? How do they impact the efficiency of teaching rounds? Are attendings who consistently apply these models more effective in providing feedback or assessing training milestones? How much training and practice is required to incorporate these teaching models in the inpatient environment?

Given the time pressure and increasing complexity of medical care in the hospital, coupled with the evolving needs and resources of our learners, we must seek innovative educational practices from sources outside our hospitals to provide the best possible training in hospital medicine. An outstanding recent review by Martin et al. provided an overview of other strategies for teaching in today's environment.[10] We also have much to learn from our colleagues in outpatient medicine, not only in clinical care, but also in medical education. And we have much that we have learned about teaching as hospitalists that needs to be more broadly disseminated.

Hospitalists who teach in the clinical environment face challenges that include increased workload,[1] perception among trainees that there is less time to teach,[2] and competition with electronic devices for teaching engagement.[3, 4] In view of these and other challenges, we believe there is potentially much to gain from considering and adapting educational techniques that have been successful in nonhospital and even nonmedical domains. Innovative teaching methods include those designed for the grade‐school classroom (Courage to Teach,[5] Teaching With Love and Logic[6]), and the business world (Teaching Smart People How to Learn,[7] The Back of the Napkin[8]), among other nonmedical professions. Within medicine, we can also re‐examine strategies long utilized in the ambulatory setting. Pascoe and colleagues offer an important example of this in their review of one‐minute preceptor (OMP) and SNAPPS, techniques developed by our colleagues in the outpatient setting but with great potential for framing discussion of clinical reasoning in the inpatient space.[9]

Applying OMP and SNAPPS to inpatient teaching presents some challenges but also genuine opportunities not found in traditional outpatient teaching. As noted by the authors, unlike the solitary learner typical of the outpatient setting, in the inpatient setting the attending is more commonly working with a group of learners of multiple levels and sometimes multiple disciplines. Furthermore, the supervising resident typical of inpatient teams is a learner who inhabits the roles of both trainee and teacher. One can imagine that if OMP and SNAPPs are applied with absolute fidelity to the inpatient setting, without reflection on venue, the teaching encounter might be overly focused on the presenting learner, leaving the rest of the team unattended to, disengaged, and not benefitting from the models. Therefore, attention to group engagement in the process is necessary for successful adaptation. Both models have the potential to help organize the group dynamic during rounds to promote broad participation. The authors describe some examples of how to engage various group members in different steps. It is worth highlighting a few key themes that enable successful use of these models in the inpatient setting.

One key theme is to teach the model to the supervising resident at the beginning of the rotation and agree, before rounds, how the attending and resident will interact as coleaders of the discussion. Because these models offer a stepwise approach to going through a case with a learner, they have the potential to demystify the teaching process, offering an accessible framework for supervising residents to learn teaching both by practicing and by comprehending what their attending is doing to lead a team through a case discussion. With attending support, the supervising resident can be encouraged to manage the team discussion, leading the team using either approach. It can be helpful to touch base briefly before rounds each day to define the teaching roles, giving the resident progressively more responsibility leading the discussion as the rotation progresses.

Another key theme is to use graduated participation. As the authors note, the group must be engaged in the discussion, and the example scenarios illustrate each step of the models being applied to the group. To ensure that the entire group remains eager to partake, the leader must maintain a nonthreatening teaching atmosphere, organizing participation in a way that does not shame learners or undermine the roles people inhabit. To this end, it can be helpful to direct questions to particular members or levels of the group at a time. When expanding participation around a specific question or concept, always work from junior members to senior members, never imposing the reverse. This principle is clearly not exclusive to using these models, but is requisite to successful adaptation of these traditionally dyadic models, in which there is no particular attention to group dynamics within the framework.

A third key theme is to utilize the unique expertise of the other health professionals on the team in steps 4, 5, and 6 of SNAPPS and step 3 of OMP. In step 4 and 5 of SNAPPS, when the teaching attending introduces the team to the model, it is important to encourage them to probe not just the teacher but other disciplines on the team for input. In the inpatient setting, these steps provide an organized point in the discussion in which to involve the other members of the professional team, modeling collaborative interdisciplinary practice.

As Pascoe et al. point out, there are limited studies of OMP and SNAPPS as teaching models in the inpatient environment. This should stimulate academic hospitalists with interest in medical education research to consider how these models might be studied. For example, in comparison to traditional inpatient teaching rounds, do these approaches provide equivalent content coverage? How do they impact the efficiency of teaching rounds? Are attendings who consistently apply these models more effective in providing feedback or assessing training milestones? How much training and practice is required to incorporate these teaching models in the inpatient environment?

Given the time pressure and increasing complexity of medical care in the hospital, coupled with the evolving needs and resources of our learners, we must seek innovative educational practices from sources outside our hospitals to provide the best possible training in hospital medicine. An outstanding recent review by Martin et al. provided an overview of other strategies for teaching in today's environment.[10] We also have much to learn from our colleagues in outpatient medicine, not only in clinical care, but also in medical education. And we have much that we have learned about teaching as hospitalists that needs to be more broadly disseminated.

Hospitalists who teach in the clinical environment face challenges that include increased workload,[1] perception among trainees that there is less time to teach,[2] and competition with electronic devices for teaching engagement.[3, 4] In view of these and other challenges, we believe there is potentially much to gain from considering and adapting educational techniques that have been successful in nonhospital and even nonmedical domains. Innovative teaching methods include those designed for the grade‐school classroom (Courage to Teach,[5] Teaching With Love and Logic[6]), and the business world (Teaching Smart People How to Learn,[7] The Back of the Napkin[8]), among other nonmedical professions. Within medicine, we can also re‐examine strategies long utilized in the ambulatory setting. Pascoe and colleagues offer an important example of this in their review of one‐minute preceptor (OMP) and SNAPPS, techniques developed by our colleagues in the outpatient setting but with great potential for framing discussion of clinical reasoning in the inpatient space.[9]

Applying OMP and SNAPPS to inpatient teaching presents some challenges but also genuine opportunities not found in traditional outpatient teaching. As noted by the authors, unlike the solitary learner typical of the outpatient setting, in the inpatient setting the attending is more commonly working with a group of learners of multiple levels and sometimes multiple disciplines. Furthermore, the supervising resident typical of inpatient teams is a learner who inhabits the roles of both trainee and teacher. One can imagine that if OMP and SNAPPs are applied with absolute fidelity to the inpatient setting, without reflection on venue, the teaching encounter might be overly focused on the presenting learner, leaving the rest of the team unattended to, disengaged, and not benefitting from the models. Therefore, attention to group engagement in the process is necessary for successful adaptation. Both models have the potential to help organize the group dynamic during rounds to promote broad participation. The authors describe some examples of how to engage various group members in different steps. It is worth highlighting a few key themes that enable successful use of these models in the inpatient setting.

One key theme is to teach the model to the supervising resident at the beginning of the rotation and agree, before rounds, how the attending and resident will interact as coleaders of the discussion. Because these models offer a stepwise approach to going through a case with a learner, they have the potential to demystify the teaching process, offering an accessible framework for supervising residents to learn teaching both by practicing and by comprehending what their attending is doing to lead a team through a case discussion. With attending support, the supervising resident can be encouraged to manage the team discussion, leading the team using either approach. It can be helpful to touch base briefly before rounds each day to define the teaching roles, giving the resident progressively more responsibility leading the discussion as the rotation progresses.

Another key theme is to use graduated participation. As the authors note, the group must be engaged in the discussion, and the example scenarios illustrate each step of the models being applied to the group. To ensure that the entire group remains eager to partake, the leader must maintain a nonthreatening teaching atmosphere, organizing participation in a way that does not shame learners or undermine the roles people inhabit. To this end, it can be helpful to direct questions to particular members or levels of the group at a time. When expanding participation around a specific question or concept, always work from junior members to senior members, never imposing the reverse. This principle is clearly not exclusive to using these models, but is requisite to successful adaptation of these traditionally dyadic models, in which there is no particular attention to group dynamics within the framework.

A third key theme is to utilize the unique expertise of the other health professionals on the team in steps 4, 5, and 6 of SNAPPS and step 3 of OMP. In step 4 and 5 of SNAPPS, when the teaching attending introduces the team to the model, it is important to encourage them to probe not just the teacher but other disciplines on the team for input. In the inpatient setting, these steps provide an organized point in the discussion in which to involve the other members of the professional team, modeling collaborative interdisciplinary practice.

As Pascoe et al. point out, there are limited studies of OMP and SNAPPS as teaching models in the inpatient environment. This should stimulate academic hospitalists with interest in medical education research to consider how these models might be studied. For example, in comparison to traditional inpatient teaching rounds, do these approaches provide equivalent content coverage? How do they impact the efficiency of teaching rounds? Are attendings who consistently apply these models more effective in providing feedback or assessing training milestones? How much training and practice is required to incorporate these teaching models in the inpatient environment?

Given the time pressure and increasing complexity of medical care in the hospital, coupled with the evolving needs and resources of our learners, we must seek innovative educational practices from sources outside our hospitals to provide the best possible training in hospital medicine. An outstanding recent review by Martin et al. provided an overview of other strategies for teaching in today's environment.[10] We also have much to learn from our colleagues in outpatient medicine, not only in clinical care, but also in medical education. And we have much that we have learned about teaching as hospitalists that needs to be more broadly disseminated.

Mrs. S arrived to the medicine service at our hospital by ambulance transport at 9:00 _pm. The intern on call received a page from the nurse, Mrs. S has arrived. She is confused. Please assess. As is often the case, the intern had no prior knowledge of the patient's arrival, and review of medical records indicated that Mrs. S had never been seen at our hospital before.

The intern went to the bedside to assess the patient and found an elderly woman who appeared confused and was unable to provider her medical history, reason for the transfer, or details about her recent hospital course.

A few minutes later, the patient's son arrived at the bedside asking about her plan of care. The intern looked through the stack of papers in the envelope by her chart, and was able to locate reports of a recent chest x‐ray and abdominal computed tomography, as well as copies of brief progress notes, but was unable to find a transfer summary detailing her prior 5 days of hospitalization or reason for transfer. The patient's son was able to give some information, but he had just returned from a business trip and was not up to date on the details of his mother's hospital stay. Based on her son's input, the intern concluded the patient's somnolence was not her baseline; he performed an arterial blood gas and blood work, revealing profound acidemia and hyponatremia of unclear acuity. Mrs. S became hypotensive, requiring transfer to the intensive care unit. Several days later, she died.

This scenario highlights the potential dangers associated with patient transfers between acute care hospitals, known as interhospital transfer (IHT). Unfortunately, the described scenario is not a rare event.[1, 2] Most providers who care for transferred patients can recount similar challenges when caring for IHT patients.[3]

Patient transfers from 1 hospital to another are common, affecting nearly 1 in 20 Medicare patients admitted to the intensive care unit[4] and up to 50% of patients presenting with acute myocardial infarction,[5] although reasons for transfer remain largely unstudied. The Emergency Medical Treatment and Active Labor Act requires a hospital to transfer patients who require a more specialized service unavailable at the subject institution, or when medical benefits outweigh the increased risks to the individual.[6] Yet, this broad standard provides little guidance to clinicians in practice.

Identifying which patients may benefit from transfer is an ambiguous and subjective process. Studies show little agreement between the reasons cited for transfer among patients, transferring physicians, and receiving physicians,[7] and incentives for transfer are often different between each stakeholder. For example, patients or families might initiate transfer for a second opinion from a fresh set of eyes because of a grim or uncertain prognosis or in the hope of a more promising or definitive medical opinion. Similarly, referring physicians may initiate transfer for particular procedures, surgeries, or consultations that the receiving physician may ultimately decide will be of little clinical benefit to the patient. Such heightened expectations and changes to the care plan as agreed on by the patient and referring physician may affect the patient's perceptions of care at the receiving institution, although exactly how remains unknown. Alternatively, patients and families may desire transfer because of previously established relationships with providers at another institution, or they may be dissatisfied with certain aspects of care at the referring institution. Referring institutions may initiate transfer for a variety of reasons, including inability to provide a needed procedure or test, patient/family preference, or protocol, among others. Receiving hospitals usually have an interest in maintaining a large referral base for the sake of both revenue and reputation, but may also view accepting transfers as part of their larger mission to provide expert consultation and specialty services that may not be available at the referring institution. Additional proposed benefits include strengthening provider networks, promoting clinical diversity, and improving the educational experience of trainees often present at the accepting institution. Although patients, providers, and referring and accepting hospitals all undoubtedly benefit from various aspects of the IHT, further research is needed to more clearly identify which patients are most likely to benefit from transfer and why.

Once the decision to transfer/accept a patient has been made, there are no clear guidelines over how this process should be executed. For this reason, care providers at community hospitals describe IHT as frustrating and time consuming.[8] Referring providers may face challenges identifying an accepting hospital due to the limited capacity of the receiving institution, reaching the correct receiving physician, and managing delays in transfer once the patient is accepted.[8] Similarly, accepting physicians may be frustrated by the time waste associated with accepting a patient that ends up transferred to another facility, limited authority to triage the patient to the most appropriate accepting service, inability to predict time of patient arrival, and missing pieces of critical information at time of patient arrival, among other reasons. Furthermore, incompatible electronic health records make access to data from the referring institution difficult. For example, without standards for transferring imaging, patients may undergo unnecessary and costly duplicate imaging leading to delay in needed procedures. Existing guidelines are largely focused on equipment and expertise required for the physical transfer of the patient, but fail to consider other aspects of the transfer process that may be critical for patient safety such as protocols for communication of patient information and transfer of completed imaging. As such, hospitals are largely left to devise their own protocols for IHT, which often differ between hospitals as well as between different services within 1 hospital.[1, 3]

Although it is true that many patients benefit from IHT, the process introduces inherent vulnerability into healthcare delivery. Moving a patient between facilities exposes that individual to risks associated with discontinuity of care, well described in the literature on intrahospital patient handoffs (ie, the transfer of patient care responsibility from 1 provider to another within 1 hospital), which can lead to excessive costs and poor patient outcomes.[9] Presumably, such risks are even greater for patients transferred between hospitals than for those transferred between providers within 1 hospital, because system factors like electronic health records, nursing and ancillary staff continuity, and accessibility of transferring provider are not in place to mitigate communication gaps. Furthermore, unlike discharges home or to subacute care facilities, also known to be error prone and lead to adverse events,[10, 11] in the case of IHT, patients are often more acutely ill and less stable. In fact, limited data suggest that aside from a select subset of patients requiring specialized care, individuals transferred may have increased resource utilization and greater‐than‐expected mortality than those who are not transferred.[1, 2, 12] Moreover, these findings may not be entirely attributable to medical complexity among transferred patients.

Today, the process of IHT varies tremendously across US hospitals,[1] differences that may have significant implications for both cost and patient safety outcomes. Standardization of IHT, including patient selection and information exchange between transferring and accepting providers/emnstitutions, is imperative to improve the quality and safety of this process. As demonstrated with other common, high‐risk care transitions, such as intrahospital patient handoffs and patient discharge, creating basic guidelines of practice (such as including important data elements at time of care transfer)[13, 14] is necessary to improve quality of the care transition.

However, to achieve high‐quality standardization, we must first methodologically conduct rigorous clinical research to understand fundamental issues of the IHT process, including why patients are transferred (from the perspective of patients and transferring and accepting institutions), which patients benefit most from transfer and why, and how various IHT processes impact health outcomes. Interventions such as communication and data transfer tools, feedback mechanisms between referring and accepting institutions, and other evidence‐based guidelines can then be designed to improve IHT based on the findings of this research while still allowing for flexibility of individual patient needs. Additional work is then needed to implement and rigorously evaluate the effects of such interventions on patient and provider outcomes including, but not limited to, length of stay, adverse events, mortality, readmissions, and patient satisfaction measures. In summary, by focusing research and quality improvement initiatives on these vital questions, we can begin to improve the quality of care we provide to patients during this critical transition of care.

Mrs. S arrived to the medicine service at our hospital by ambulance transport at 9:00 _pm. The intern on call received a page from the nurse, Mrs. S has arrived. She is confused. Please assess. As is often the case, the intern had no prior knowledge of the patient's arrival, and review of medical records indicated that Mrs. S had never been seen at our hospital before.

The intern went to the bedside to assess the patient and found an elderly woman who appeared confused and was unable to provider her medical history, reason for the transfer, or details about her recent hospital course.

A few minutes later, the patient's son arrived at the bedside asking about her plan of care. The intern looked through the stack of papers in the envelope by her chart, and was able to locate reports of a recent chest x‐ray and abdominal computed tomography, as well as copies of brief progress notes, but was unable to find a transfer summary detailing her prior 5 days of hospitalization or reason for transfer. The patient's son was able to give some information, but he had just returned from a business trip and was not up to date on the details of his mother's hospital stay. Based on her son's input, the intern concluded the patient's somnolence was not her baseline; he performed an arterial blood gas and blood work, revealing profound acidemia and hyponatremia of unclear acuity. Mrs. S became hypotensive, requiring transfer to the intensive care unit. Several days later, she died.

This scenario highlights the potential dangers associated with patient transfers between acute care hospitals, known as interhospital transfer (IHT). Unfortunately, the described scenario is not a rare event.[1, 2] Most providers who care for transferred patients can recount similar challenges when caring for IHT patients.[3]

Patient transfers from 1 hospital to another are common, affecting nearly 1 in 20 Medicare patients admitted to the intensive care unit[4] and up to 50% of patients presenting with acute myocardial infarction,[5] although reasons for transfer remain largely unstudied. The Emergency Medical Treatment and Active Labor Act requires a hospital to transfer patients who require a more specialized service unavailable at the subject institution, or when medical benefits outweigh the increased risks to the individual.[6] Yet, this broad standard provides little guidance to clinicians in practice.

Identifying which patients may benefit from transfer is an ambiguous and subjective process. Studies show little agreement between the reasons cited for transfer among patients, transferring physicians, and receiving physicians,[7] and incentives for transfer are often different between each stakeholder. For example, patients or families might initiate transfer for a second opinion from a fresh set of eyes because of a grim or uncertain prognosis or in the hope of a more promising or definitive medical opinion. Similarly, referring physicians may initiate transfer for particular procedures, surgeries, or consultations that the receiving physician may ultimately decide will be of little clinical benefit to the patient. Such heightened expectations and changes to the care plan as agreed on by the patient and referring physician may affect the patient's perceptions of care at the receiving institution, although exactly how remains unknown. Alternatively, patients and families may desire transfer because of previously established relationships with providers at another institution, or they may be dissatisfied with certain aspects of care at the referring institution. Referring institutions may initiate transfer for a variety of reasons, including inability to provide a needed procedure or test, patient/family preference, or protocol, among others. Receiving hospitals usually have an interest in maintaining a large referral base for the sake of both revenue and reputation, but may also view accepting transfers as part of their larger mission to provide expert consultation and specialty services that may not be available at the referring institution. Additional proposed benefits include strengthening provider networks, promoting clinical diversity, and improving the educational experience of trainees often present at the accepting institution. Although patients, providers, and referring and accepting hospitals all undoubtedly benefit from various aspects of the IHT, further research is needed to more clearly identify which patients are most likely to benefit from transfer and why.

Once the decision to transfer/accept a patient has been made, there are no clear guidelines over how this process should be executed. For this reason, care providers at community hospitals describe IHT as frustrating and time consuming.[8] Referring providers may face challenges identifying an accepting hospital due to the limited capacity of the receiving institution, reaching the correct receiving physician, and managing delays in transfer once the patient is accepted.[8] Similarly, accepting physicians may be frustrated by the time waste associated with accepting a patient that ends up transferred to another facility, limited authority to triage the patient to the most appropriate accepting service, inability to predict time of patient arrival, and missing pieces of critical information at time of patient arrival, among other reasons. Furthermore, incompatible electronic health records make access to data from the referring institution difficult. For example, without standards for transferring imaging, patients may undergo unnecessary and costly duplicate imaging leading to delay in needed procedures. Existing guidelines are largely focused on equipment and expertise required for the physical transfer of the patient, but fail to consider other aspects of the transfer process that may be critical for patient safety such as protocols for communication of patient information and transfer of completed imaging. As such, hospitals are largely left to devise their own protocols for IHT, which often differ between hospitals as well as between different services within 1 hospital.[1, 3]

Although it is true that many patients benefit from IHT, the process introduces inherent vulnerability into healthcare delivery. Moving a patient between facilities exposes that individual to risks associated with discontinuity of care, well described in the literature on intrahospital patient handoffs (ie, the transfer of patient care responsibility from 1 provider to another within 1 hospital), which can lead to excessive costs and poor patient outcomes.[9] Presumably, such risks are even greater for patients transferred between hospitals than for those transferred between providers within 1 hospital, because system factors like electronic health records, nursing and ancillary staff continuity, and accessibility of transferring provider are not in place to mitigate communication gaps. Furthermore, unlike discharges home or to subacute care facilities, also known to be error prone and lead to adverse events,[10, 11] in the case of IHT, patients are often more acutely ill and less stable. In fact, limited data suggest that aside from a select subset of patients requiring specialized care, individuals transferred may have increased resource utilization and greater‐than‐expected mortality than those who are not transferred.[1, 2, 12] Moreover, these findings may not be entirely attributable to medical complexity among transferred patients.

Today, the process of IHT varies tremendously across US hospitals,[1] differences that may have significant implications for both cost and patient safety outcomes. Standardization of IHT, including patient selection and information exchange between transferring and accepting providers/emnstitutions, is imperative to improve the quality and safety of this process. As demonstrated with other common, high‐risk care transitions, such as intrahospital patient handoffs and patient discharge, creating basic guidelines of practice (such as including important data elements at time of care transfer)[13, 14] is necessary to improve quality of the care transition.

However, to achieve high‐quality standardization, we must first methodologically conduct rigorous clinical research to understand fundamental issues of the IHT process, including why patients are transferred (from the perspective of patients and transferring and accepting institutions), which patients benefit most from transfer and why, and how various IHT processes impact health outcomes. Interventions such as communication and data transfer tools, feedback mechanisms between referring and accepting institutions, and other evidence‐based guidelines can then be designed to improve IHT based on the findings of this research while still allowing for flexibility of individual patient needs. Additional work is then needed to implement and rigorously evaluate the effects of such interventions on patient and provider outcomes including, but not limited to, length of stay, adverse events, mortality, readmissions, and patient satisfaction measures. In summary, by focusing research and quality improvement initiatives on these vital questions, we can begin to improve the quality of care we provide to patients during this critical transition of care.

Mrs. S arrived to the medicine service at our hospital by ambulance transport at 9:00 _pm. The intern on call received a page from the nurse, Mrs. S has arrived. She is confused. Please assess. As is often the case, the intern had no prior knowledge of the patient's arrival, and review of medical records indicated that Mrs. S had never been seen at our hospital before.

The intern went to the bedside to assess the patient and found an elderly woman who appeared confused and was unable to provider her medical history, reason for the transfer, or details about her recent hospital course.

A few minutes later, the patient's son arrived at the bedside asking about her plan of care. The intern looked through the stack of papers in the envelope by her chart, and was able to locate reports of a recent chest x‐ray and abdominal computed tomography, as well as copies of brief progress notes, but was unable to find a transfer summary detailing her prior 5 days of hospitalization or reason for transfer. The patient's son was able to give some information, but he had just returned from a business trip and was not up to date on the details of his mother's hospital stay. Based on her son's input, the intern concluded the patient's somnolence was not her baseline; he performed an arterial blood gas and blood work, revealing profound acidemia and hyponatremia of unclear acuity. Mrs. S became hypotensive, requiring transfer to the intensive care unit. Several days later, she died.

This scenario highlights the potential dangers associated with patient transfers between acute care hospitals, known as interhospital transfer (IHT). Unfortunately, the described scenario is not a rare event.[1, 2] Most providers who care for transferred patients can recount similar challenges when caring for IHT patients.[3]

Patient transfers from 1 hospital to another are common, affecting nearly 1 in 20 Medicare patients admitted to the intensive care unit[4] and up to 50% of patients presenting with acute myocardial infarction,[5] although reasons for transfer remain largely unstudied. The Emergency Medical Treatment and Active Labor Act requires a hospital to transfer patients who require a more specialized service unavailable at the subject institution, or when medical benefits outweigh the increased risks to the individual.[6] Yet, this broad standard provides little guidance to clinicians in practice.

Identifying which patients may benefit from transfer is an ambiguous and subjective process. Studies show little agreement between the reasons cited for transfer among patients, transferring physicians, and receiving physicians,[7] and incentives for transfer are often different between each stakeholder. For example, patients or families might initiate transfer for a second opinion from a fresh set of eyes because of a grim or uncertain prognosis or in the hope of a more promising or definitive medical opinion. Similarly, referring physicians may initiate transfer for particular procedures, surgeries, or consultations that the receiving physician may ultimately decide will be of little clinical benefit to the patient. Such heightened expectations and changes to the care plan as agreed on by the patient and referring physician may affect the patient's perceptions of care at the receiving institution, although exactly how remains unknown. Alternatively, patients and families may desire transfer because of previously established relationships with providers at another institution, or they may be dissatisfied with certain aspects of care at the referring institution. Referring institutions may initiate transfer for a variety of reasons, including inability to provide a needed procedure or test, patient/family preference, or protocol, among others. Receiving hospitals usually have an interest in maintaining a large referral base for the sake of both revenue and reputation, but may also view accepting transfers as part of their larger mission to provide expert consultation and specialty services that may not be available at the referring institution. Additional proposed benefits include strengthening provider networks, promoting clinical diversity, and improving the educational experience of trainees often present at the accepting institution. Although patients, providers, and referring and accepting hospitals all undoubtedly benefit from various aspects of the IHT, further research is needed to more clearly identify which patients are most likely to benefit from transfer and why.

Once the decision to transfer/accept a patient has been made, there are no clear guidelines over how this process should be executed. For this reason, care providers at community hospitals describe IHT as frustrating and time consuming.[8] Referring providers may face challenges identifying an accepting hospital due to the limited capacity of the receiving institution, reaching the correct receiving physician, and managing delays in transfer once the patient is accepted.[8] Similarly, accepting physicians may be frustrated by the time waste associated with accepting a patient that ends up transferred to another facility, limited authority to triage the patient to the most appropriate accepting service, inability to predict time of patient arrival, and missing pieces of critical information at time of patient arrival, among other reasons. Furthermore, incompatible electronic health records make access to data from the referring institution difficult. For example, without standards for transferring imaging, patients may undergo unnecessary and costly duplicate imaging leading to delay in needed procedures. Existing guidelines are largely focused on equipment and expertise required for the physical transfer of the patient, but fail to consider other aspects of the transfer process that may be critical for patient safety such as protocols for communication of patient information and transfer of completed imaging. As such, hospitals are largely left to devise their own protocols for IHT, which often differ between hospitals as well as between different services within 1 hospital.[1, 3]

Although it is true that many patients benefit from IHT, the process introduces inherent vulnerability into healthcare delivery. Moving a patient between facilities exposes that individual to risks associated with discontinuity of care, well described in the literature on intrahospital patient handoffs (ie, the transfer of patient care responsibility from 1 provider to another within 1 hospital), which can lead to excessive costs and poor patient outcomes.[9] Presumably, such risks are even greater for patients transferred between hospitals than for those transferred between providers within 1 hospital, because system factors like electronic health records, nursing and ancillary staff continuity, and accessibility of transferring provider are not in place to mitigate communication gaps. Furthermore, unlike discharges home or to subacute care facilities, also known to be error prone and lead to adverse events,[10, 11] in the case of IHT, patients are often more acutely ill and less stable. In fact, limited data suggest that aside from a select subset of patients requiring specialized care, individuals transferred may have increased resource utilization and greater‐than‐expected mortality than those who are not transferred.[1, 2, 12] Moreover, these findings may not be entirely attributable to medical complexity among transferred patients.

Today, the process of IHT varies tremendously across US hospitals,[1] differences that may have significant implications for both cost and patient safety outcomes. Standardization of IHT, including patient selection and information exchange between transferring and accepting providers/emnstitutions, is imperative to improve the quality and safety of this process. As demonstrated with other common, high‐risk care transitions, such as intrahospital patient handoffs and patient discharge, creating basic guidelines of practice (such as including important data elements at time of care transfer)[13, 14] is necessary to improve quality of the care transition.

However, to achieve high‐quality standardization, we must first methodologically conduct rigorous clinical research to understand fundamental issues of the IHT process, including why patients are transferred (from the perspective of patients and transferring and accepting institutions), which patients benefit most from transfer and why, and how various IHT processes impact health outcomes. Interventions such as communication and data transfer tools, feedback mechanisms between referring and accepting institutions, and other evidence‐based guidelines can then be designed to improve IHT based on the findings of this research while still allowing for flexibility of individual patient needs. Additional work is then needed to implement and rigorously evaluate the effects of such interventions on patient and provider outcomes including, but not limited to, length of stay, adverse events, mortality, readmissions, and patient satisfaction measures. In summary, by focusing research and quality improvement initiatives on these vital questions, we can begin to improve the quality of care we provide to patients during this critical transition of care.

Bronchiolitis is the most common cause of hospitalization in infancy, with estimated annual US costs of over $1.7 billion.[1] The last 2 decades have seen numerous thoughtful and well‐designed research studies but little improvement in the value of care.[1, 2, 3, 4] The diagnosis and treatment section of the recently released 2014 American Academy of Pediatrics (AAP) Clinical Practice Guideline for bronchiolitis contains 7 should not's and 3 should's,[3] with the only clear affirmative recommendations related to the history and physical and to the use of supplemental fluids. As supported by several systematic reviews and randomized controlled trials, the use of respiratory treatments, including ‐agonists, racemic epinephrine, and hypertonic saline, was discouraged. There continues to be significant variation in care for patients with bronchiolitis[5, 6] and rigorous evidence was lacking on when a child could be safely discharged home.

Mansbach and colleagues in the Multicenter Airway Research Collaboration (MARC‐30) provide the best evidence to date on the clinical course of bronchiolitis and present multicenter data upon which to build evidence‐based discharge criteria.[7] In their prospective cohort study of 16 US children's hospitals, Mansbach et al. sought to answer 3 research questions: (1) In infants hospitalized with bronchiolitis, what is the time to clinical improvement? (2) What is the risk of clinical worsening after standardized improvement criteria are met? (3) What discharge criteria might balance both timely discharge and very low readmission risk? In an analytic cohort of 1916 children <2 years of age with a physician diagnosis of bronchiolitis, the time from onset of difficulty breathing until clinical improvement was a median of 4 days, with a 75th percentile of 7.5 days. Of the 1702 children who clinically improved before discharge, only 76 (4%) then worsened. Although there are some limitations to how these criteria were assessed, the authors' work supports discharge criteria of (1) no or mild and stable or improving retractions, (2) stable or improving respiratory rate that is below the 90th percentile for age, (3) estimated room air saturation of 90% without any points <88%, and (4) clinician assessment of the child maintaining adequate oral hydration, regardless of use of intravenous fluids.

Three limitations warrant consideration when interpreting the study results. First, the MARC‐30 investigators oversampled from the intensive care unit and excluded 109 children with a hospital length of stay (LOS) <1 day. Although it is uncertain what effect these decisions would have on worsening after improving, both would overestimate the LOS in the sampled population at study hospitals. It is likely that the median LOS and 75th percentile of 4 and 7.5 days, respectively, are higher than what hospital medicine physicians saw at these hospitals. Second, the study team did not use a scoring tool. The authors note that the holistic assessments clinicians used to estimate respiratory rate and oxygen saturation may be more similar to standard clinical practice more than a calculated mean. This raises an important question: If less numerous data might lead to more information and knowledge, might they also lead to reliability and validity concerns? Given an absence of a structured, validated assessment of these severity indicators, it seems possible clinicians worked backward from the holistic assessment of this child is ready to go home and then entered data to support their larger assessment. This would tend to bias toward lower proportions of worsening after clinical improvement. Third, the once‐daily review of the medical record led to less precise estimates of each event including time from difficulty breathing to improvement and LOS. In addition to the absence of a scoring tool, this likely adds a modest bias toward underdetection of clinical worsening after improvement, because observations from discharged children were effectively censored from analysis. Importantly the low readmission rates suggest neither of those biases is substantial.

Several of the findings in this article support recent changes to the recommendations in the 2014 AAP Bronchiolitis Clinical Practice Guideline.[3] Although there is no recommendation on discharge readiness, Mansbach and colleagues found that an operationalization of the core criteria outlined in the 2006 version of the AAP Bronchiolitis Clinical Practice Guideline would result in a low proportion of subsequent clinical worsening.[8] This study also informs and supports an additional change to the AAP's 2006 guideline recommendation on continuous pulse oximetry. Key Action Statement 6b in the 2014 guideline notes Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis, expanding the recommendation from the 2006 guideline discouraging continuous pulse oximetry as the child's clinical course improves.[3, 8] Mansbach and colleagues found that removing the lower desaturation threshold of 88% improved the percentage of children who met criteria, with no changes in proportion subsequently worsening. With an improvement criterion of average oxygen saturation threshold of 95%, less than half of the children met this criteria before discharge, and an increased percentage (5%) clinically worsened, presumably due to clinically inconsequential desaturations to 94%. The less stringent the pulse oximetry criteria, the better their improvement criteria performed. This study adds to the modest literature on how overuse of continuous pulse oximetry may prolong hospitalization, leading to nonvalue‐added care and potentially increasing the risk of iatrogenic harm.[9, 10, 11]

Another strength of this study is the extensive viral testing on nasal aspirates. The absence of an association between individual viral pathogen or coinfection on the risk of worsening after improving further supports the recommendation against viral testing. The authors also identified a large group of children with a very low risk of worsening after an improving course: children 2 months, born at term, and who did not present with severe retractions. This finding, which will resonate with clinicians who care for patients with bronchiolitis, provides additional data on a group likely to have short hospitalization and unlikely to benefit from therapies. It also identifies a group of children with increased risk of worsening, which could be targeted for future research efforts on therapies such as hypertonic saline and high‐flow nasal cannula, where the evidence is mixed and inconclusive.

Both the MARC‐30 study and the 2014 AAP guidelines are tremendous contributions to the scientific literature on this common, costly, and often frustrating disease for clinicians and families alike. More important, however, will be implementation and dissemination efforts to ensure children benefit from this new knowledge. After the 2006 AAP guidelines, there was some evidence of improved care[12] but remaining profound hospital‐level variation.[5] Immediate next steps to improve bronchiolitis care should include interventions to standardize evidence‐based discharge criteria and reduce the overuse of nonevidence‐based care. Local clinical practice guidelines aid in the early phases of standardization, but without work and willpower in the implementation and sustain phase, their effect may be modest.[13] This study and the new guideline raise several important T3[14] or how questions for pediatric hospital medicine clinicians, researchers, and improvers. First, how can evidence‐based discharge criteria, such as those presented here, be applied reliably and broadly at the point of care? White and colleagues at Cincinnati shared a strategy that will benefit from further testing and adaptation.[15] Second, how can continuous pulse oximetry be either greatly reduced or have its data put in a broader context to inform decision making? Relatedly, which strategy is more effective and for whom? Finally, what incentives at the hospital and policy level are most effective in helping physicians to choose wisely[16] and do less?

Answering these questions will be crucial to ensure the knowledge produced from Mansbach and colleagues benefits the hundreds of thousands of children hospitalized with bronchiolitis each year.

Disclosure

Nothing to report.

Bronchiolitis is the most common cause of hospitalization in infancy, with estimated annual US costs of over $1.7 billion.[1] The last 2 decades have seen numerous thoughtful and well‐designed research studies but little improvement in the value of care.[1, 2, 3, 4] The diagnosis and treatment section of the recently released 2014 American Academy of Pediatrics (AAP) Clinical Practice Guideline for bronchiolitis contains 7 should not's and 3 should's,[3] with the only clear affirmative recommendations related to the history and physical and to the use of supplemental fluids. As supported by several systematic reviews and randomized controlled trials, the use of respiratory treatments, including ‐agonists, racemic epinephrine, and hypertonic saline, was discouraged. There continues to be significant variation in care for patients with bronchiolitis[5, 6] and rigorous evidence was lacking on when a child could be safely discharged home.

Mansbach and colleagues in the Multicenter Airway Research Collaboration (MARC‐30) provide the best evidence to date on the clinical course of bronchiolitis and present multicenter data upon which to build evidence‐based discharge criteria.[7] In their prospective cohort study of 16 US children's hospitals, Mansbach et al. sought to answer 3 research questions: (1) In infants hospitalized with bronchiolitis, what is the time to clinical improvement? (2) What is the risk of clinical worsening after standardized improvement criteria are met? (3) What discharge criteria might balance both timely discharge and very low readmission risk? In an analytic cohort of 1916 children <2 years of age with a physician diagnosis of bronchiolitis, the time from onset of difficulty breathing until clinical improvement was a median of 4 days, with a 75th percentile of 7.5 days. Of the 1702 children who clinically improved before discharge, only 76 (4%) then worsened. Although there are some limitations to how these criteria were assessed, the authors' work supports discharge criteria of (1) no or mild and stable or improving retractions, (2) stable or improving respiratory rate that is below the 90th percentile for age, (3) estimated room air saturation of 90% without any points <88%, and (4) clinician assessment of the child maintaining adequate oral hydration, regardless of use of intravenous fluids.

Three limitations warrant consideration when interpreting the study results. First, the MARC‐30 investigators oversampled from the intensive care unit and excluded 109 children with a hospital length of stay (LOS) <1 day. Although it is uncertain what effect these decisions would have on worsening after improving, both would overestimate the LOS in the sampled population at study hospitals. It is likely that the median LOS and 75th percentile of 4 and 7.5 days, respectively, are higher than what hospital medicine physicians saw at these hospitals. Second, the study team did not use a scoring tool. The authors note that the holistic assessments clinicians used to estimate respiratory rate and oxygen saturation may be more similar to standard clinical practice more than a calculated mean. This raises an important question: If less numerous data might lead to more information and knowledge, might they also lead to reliability and validity concerns? Given an absence of a structured, validated assessment of these severity indicators, it seems possible clinicians worked backward from the holistic assessment of this child is ready to go home and then entered data to support their larger assessment. This would tend to bias toward lower proportions of worsening after clinical improvement. Third, the once‐daily review of the medical record led to less precise estimates of each event including time from difficulty breathing to improvement and LOS. In addition to the absence of a scoring tool, this likely adds a modest bias toward underdetection of clinical worsening after improvement, because observations from discharged children were effectively censored from analysis. Importantly the low readmission rates suggest neither of those biases is substantial.

Several of the findings in this article support recent changes to the recommendations in the 2014 AAP Bronchiolitis Clinical Practice Guideline.[3] Although there is no recommendation on discharge readiness, Mansbach and colleagues found that an operationalization of the core criteria outlined in the 2006 version of the AAP Bronchiolitis Clinical Practice Guideline would result in a low proportion of subsequent clinical worsening.[8] This study also informs and supports an additional change to the AAP's 2006 guideline recommendation on continuous pulse oximetry. Key Action Statement 6b in the 2014 guideline notes Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis, expanding the recommendation from the 2006 guideline discouraging continuous pulse oximetry as the child's clinical course improves.[3, 8] Mansbach and colleagues found that removing the lower desaturation threshold of 88% improved the percentage of children who met criteria, with no changes in proportion subsequently worsening. With an improvement criterion of average oxygen saturation threshold of 95%, less than half of the children met this criteria before discharge, and an increased percentage (5%) clinically worsened, presumably due to clinically inconsequential desaturations to 94%. The less stringent the pulse oximetry criteria, the better their improvement criteria performed. This study adds to the modest literature on how overuse of continuous pulse oximetry may prolong hospitalization, leading to nonvalue‐added care and potentially increasing the risk of iatrogenic harm.[9, 10, 11]

Another strength of this study is the extensive viral testing on nasal aspirates. The absence of an association between individual viral pathogen or coinfection on the risk of worsening after improving further supports the recommendation against viral testing. The authors also identified a large group of children with a very low risk of worsening after an improving course: children 2 months, born at term, and who did not present with severe retractions. This finding, which will resonate with clinicians who care for patients with bronchiolitis, provides additional data on a group likely to have short hospitalization and unlikely to benefit from therapies. It also identifies a group of children with increased risk of worsening, which could be targeted for future research efforts on therapies such as hypertonic saline and high‐flow nasal cannula, where the evidence is mixed and inconclusive.

Both the MARC‐30 study and the 2014 AAP guidelines are tremendous contributions to the scientific literature on this common, costly, and often frustrating disease for clinicians and families alike. More important, however, will be implementation and dissemination efforts to ensure children benefit from this new knowledge. After the 2006 AAP guidelines, there was some evidence of improved care[12] but remaining profound hospital‐level variation.[5] Immediate next steps to improve bronchiolitis care should include interventions to standardize evidence‐based discharge criteria and reduce the overuse of nonevidence‐based care. Local clinical practice guidelines aid in the early phases of standardization, but without work and willpower in the implementation and sustain phase, their effect may be modest.[13] This study and the new guideline raise several important T3[14] or how questions for pediatric hospital medicine clinicians, researchers, and improvers. First, how can evidence‐based discharge criteria, such as those presented here, be applied reliably and broadly at the point of care? White and colleagues at Cincinnati shared a strategy that will benefit from further testing and adaptation.[15] Second, how can continuous pulse oximetry be either greatly reduced or have its data put in a broader context to inform decision making? Relatedly, which strategy is more effective and for whom? Finally, what incentives at the hospital and policy level are most effective in helping physicians to choose wisely[16] and do less?

Answering these questions will be crucial to ensure the knowledge produced from Mansbach and colleagues benefits the hundreds of thousands of children hospitalized with bronchiolitis each year.

Disclosure

Nothing to report.

Bronchiolitis is the most common cause of hospitalization in infancy, with estimated annual US costs of over $1.7 billion.[1] The last 2 decades have seen numerous thoughtful and well‐designed research studies but little improvement in the value of care.[1, 2, 3, 4] The diagnosis and treatment section of the recently released 2014 American Academy of Pediatrics (AAP) Clinical Practice Guideline for bronchiolitis contains 7 should not's and 3 should's,[3] with the only clear affirmative recommendations related to the history and physical and to the use of supplemental fluids. As supported by several systematic reviews and randomized controlled trials, the use of respiratory treatments, including ‐agonists, racemic epinephrine, and hypertonic saline, was discouraged. There continues to be significant variation in care for patients with bronchiolitis[5, 6] and rigorous evidence was lacking on when a child could be safely discharged home.

Mansbach and colleagues in the Multicenter Airway Research Collaboration (MARC‐30) provide the best evidence to date on the clinical course of bronchiolitis and present multicenter data upon which to build evidence‐based discharge criteria.[7] In their prospective cohort study of 16 US children's hospitals, Mansbach et al. sought to answer 3 research questions: (1) In infants hospitalized with bronchiolitis, what is the time to clinical improvement? (2) What is the risk of clinical worsening after standardized improvement criteria are met? (3) What discharge criteria might balance both timely discharge and very low readmission risk? In an analytic cohort of 1916 children <2 years of age with a physician diagnosis of bronchiolitis, the time from onset of difficulty breathing until clinical improvement was a median of 4 days, with a 75th percentile of 7.5 days. Of the 1702 children who clinically improved before discharge, only 76 (4%) then worsened. Although there are some limitations to how these criteria were assessed, the authors' work supports discharge criteria of (1) no or mild and stable or improving retractions, (2) stable or improving respiratory rate that is below the 90th percentile for age, (3) estimated room air saturation of 90% without any points <88%, and (4) clinician assessment of the child maintaining adequate oral hydration, regardless of use of intravenous fluids.

Three limitations warrant consideration when interpreting the study results. First, the MARC‐30 investigators oversampled from the intensive care unit and excluded 109 children with a hospital length of stay (LOS) <1 day. Although it is uncertain what effect these decisions would have on worsening after improving, both would overestimate the LOS in the sampled population at study hospitals. It is likely that the median LOS and 75th percentile of 4 and 7.5 days, respectively, are higher than what hospital medicine physicians saw at these hospitals. Second, the study team did not use a scoring tool. The authors note that the holistic assessments clinicians used to estimate respiratory rate and oxygen saturation may be more similar to standard clinical practice more than a calculated mean. This raises an important question: If less numerous data might lead to more information and knowledge, might they also lead to reliability and validity concerns? Given an absence of a structured, validated assessment of these severity indicators, it seems possible clinicians worked backward from the holistic assessment of this child is ready to go home and then entered data to support their larger assessment. This would tend to bias toward lower proportions of worsening after clinical improvement. Third, the once‐daily review of the medical record led to less precise estimates of each event including time from difficulty breathing to improvement and LOS. In addition to the absence of a scoring tool, this likely adds a modest bias toward underdetection of clinical worsening after improvement, because observations from discharged children were effectively censored from analysis. Importantly the low readmission rates suggest neither of those biases is substantial.

Several of the findings in this article support recent changes to the recommendations in the 2014 AAP Bronchiolitis Clinical Practice Guideline.[3] Although there is no recommendation on discharge readiness, Mansbach and colleagues found that an operationalization of the core criteria outlined in the 2006 version of the AAP Bronchiolitis Clinical Practice Guideline would result in a low proportion of subsequent clinical worsening.[8] This study also informs and supports an additional change to the AAP's 2006 guideline recommendation on continuous pulse oximetry. Key Action Statement 6b in the 2014 guideline notes Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis, expanding the recommendation from the 2006 guideline discouraging continuous pulse oximetry as the child's clinical course improves.[3, 8] Mansbach and colleagues found that removing the lower desaturation threshold of 88% improved the percentage of children who met criteria, with no changes in proportion subsequently worsening. With an improvement criterion of average oxygen saturation threshold of 95%, less than half of the children met this criteria before discharge, and an increased percentage (5%) clinically worsened, presumably due to clinically inconsequential desaturations to 94%. The less stringent the pulse oximetry criteria, the better their improvement criteria performed. This study adds to the modest literature on how overuse of continuous pulse oximetry may prolong hospitalization, leading to nonvalue‐added care and potentially increasing the risk of iatrogenic harm.[9, 10, 11]

Another strength of this study is the extensive viral testing on nasal aspirates. The absence of an association between individual viral pathogen or coinfection on the risk of worsening after improving further supports the recommendation against viral testing. The authors also identified a large group of children with a very low risk of worsening after an improving course: children 2 months, born at term, and who did not present with severe retractions. This finding, which will resonate with clinicians who care for patients with bronchiolitis, provides additional data on a group likely to have short hospitalization and unlikely to benefit from therapies. It also identifies a group of children with increased risk of worsening, which could be targeted for future research efforts on therapies such as hypertonic saline and high‐flow nasal cannula, where the evidence is mixed and inconclusive.

Both the MARC‐30 study and the 2014 AAP guidelines are tremendous contributions to the scientific literature on this common, costly, and often frustrating disease for clinicians and families alike. More important, however, will be implementation and dissemination efforts to ensure children benefit from this new knowledge. After the 2006 AAP guidelines, there was some evidence of improved care[12] but remaining profound hospital‐level variation.[5] Immediate next steps to improve bronchiolitis care should include interventions to standardize evidence‐based discharge criteria and reduce the overuse of nonevidence‐based care. Local clinical practice guidelines aid in the early phases of standardization, but without work and willpower in the implementation and sustain phase, their effect may be modest.[13] This study and the new guideline raise several important T3[14] or how questions for pediatric hospital medicine clinicians, researchers, and improvers. First, how can evidence‐based discharge criteria, such as those presented here, be applied reliably and broadly at the point of care? White and colleagues at Cincinnati shared a strategy that will benefit from further testing and adaptation.[15] Second, how can continuous pulse oximetry be either greatly reduced or have its data put in a broader context to inform decision making? Relatedly, which strategy is more effective and for whom? Finally, what incentives at the hospital and policy level are most effective in helping physicians to choose wisely[16] and do less?

Answering these questions will be crucial to ensure the knowledge produced from Mansbach and colleagues benefits the hundreds of thousands of children hospitalized with bronchiolitis each year.

Disclosure

Nothing to report.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

The adoption of electronic health records (EHRs) in US hospitals continues to rise steeply, with nearly 60% of all hospitals having at least a basic EHR as of 2014.[1] EHRs bring with them the ability to inform and guide clinicians as they make decisions. In theory, this form of clinical decision support (CDS) ensures quality of care, reduces adverse events, and improves efficiency; in practice, experience in the field paints a mixed picture.[2, 3] This issue of the Journal of Hospital Medicine presents 3 examples of CDS that illustrate the distance between what we see as CDS' full potential and current limitations.

In the study by Herzig et al.[4] investigators took on the challenge of implementing stress ulcer prophylaxis guidelines developed by the Society of Hospital Medicine. The investigators first demonstrated that targeted electronic prompts captured patients' indications for acid suppressive therapy, and could be used to prohibit prescribers from ordering acid suppressive therapy among patients outside the intensive care unit (ICU) setting. Through an elegant interrupted time series study design deployed across 2 hospital campuses, the investigators were able to demonstrate immediate and clinically significant reduction in acid suppressive therapy outside the ICU. They further found that the impact of this reduction was augmented over time, suggesting that the electronic prompts had a sustained impact on provider ordering behavior. However, below the headlineand relevant to the limitations of CDSthe investigators noted that much of the reduction in the use of acid suppressive therapy for stress ulcer prophylaxis could be accounted for by providers' choice of another acceptable indication (eg, continuing preadmission medication). The authors speculated that the CDS intervention prompted providers to more accurately record the indication for acid suppressive therapy. It is also possible that providers simply chose an alternate indication to circumvent the decision‐support step. Perhaps as a result of these 2 offsetting factors, the actual use of acid suppressive therapy, regardless of indication, only decreased in a modest and statistically nonsignificant way, casting the true effectiveness of this CDS intervention into question.

Two other studies in this issue of the Journal of Hospital Medicine[5, 6] provide valuable insights into interactions between social and technical factors[7, 8, 9, 10] that determine the success or failure in the use of technology such as CDS to drive organizational performance. At the technical end of this sociotechnical spectrum, the study by Knight et al.[5] illustrated that a minimally configured and visually unintuitive medication decision‐support system resulted in a high number of alerts (approximately 17% of studied orders), leading to the well‐reported phenomena of alert fatigue and substantially lower response rate compared to those reported in the literature.[11, 12, 13] Moreover, the analysis suggested that response to these alerts were particularly muted among situations that were particularly high risk, including the patient being older, patient having a greater length of stay, care being delivered in the internal medicine service, resident physician being the prescriber, and the medication being on the Institute for Safe Medication Practices list of high‐alert medications. The investigators concluded that a redesign of the medication decision‐support system was needed.

The study by Chen et al.[6] illuminated how social factors pose challenges in implementing CDS. Investigators in this study were previously successful in using a combination of an education campaign and interruptive decision‐support prompts to reduce the inappropriate ordering of blood transfusions. However, even with a successful intervention, up to 30% of transfusions occurred outside of recommended guidelines. This finding prompted the investigators to analyze the free‐text reasons offered by providers for overriding the recommended guidelines. Two key patterns emerged from their structured analysis. First, many of the apparently inappropriate transfusions occurred under officially sanctioned protocols (such as stem cell transplant) that the computer system was not able to take into account in generating alerts. Second, many orders that reflected questionable practices were being entered by resident physicians, physician assistants, nurse practitioners, and nurses who were least empowered to challenge requests from senior staff.

Several practical and actionable lessons can be drawn from the 3 sets of investigators featured in this issue of the Journal of Hospital Medicine. First, all investigators defined metrics that should be tracked over time to demonstrate progress and to make iterative improvements; this discipline is needed in both academic and community settings to prioritize limited CDS resources in an objective and data‐driven way. Second, as the Herzig et al.[4] article illustrated, when it comes to evaluating the impact of CDS, we cannot be satisfied merely with process measures (eg, change in clinical documentation) at the expense of outcome measures (eg, decrease in inappropriate use of therapies). Third, as Chen et al.[6] recognized, CDS is but a component of an educational program to guide and alter clinical behavior, and must be deployed in conjunction with other educational tools such as newsletters, traditional lectures, or academic detailing. Fourth, clinicians with a stake in improving quality and safety should be on guard against the well‐documented phenomena of alert fatigue by ensuring their organization selects an appropriate framework for deciding which CDS alerts are activated andwhere possibledisplay the highest‐priority alerts in the most prominent and interruptive manner. Fifth, CDS must be maintained over time as clinical guidelines and clinicians' receptivity to each CDS evolve. Alerts that are not changing clinical behavior should either be modified or simply turned off. Sixth, free text entered as part of structured data entry (eg, while placing orders) or as reasons for overriding CDS (as in Chen et al.[6]) offer significant insights on how to optimize CDS, and should be monitored systematically on an ongoing basis to ensure the EMR addresses users' changing needs and mental models.

So what is the clinician with an interest in improving healthcare outcomes and organizational efficiency to do given CDS' limitations? One option is to wait for the science of CDS to further mature and have those advances embedded in the EMR at your organization. Another option might be to rely on the information technology and clinical informatics professionals at your organization to decide how CDS should be used locally. In 2014, these may be untenable choices for the following reasons. First, given the universal pressures to improve healthcare outcomes and contain costs,[14] healthcare organizations must use all available tools to achieve challenging performance goals. Second, as EMRs with CDS become commonplace, and as the 3 articles in this issue of the Journal of Hospital Medicine and others have illustrated, there are many opportunities to misuse or poorly implement CDS, with potentially dire consequences.[15] Third, design and deployment of effective CDS require information technology and informatics professionals to collaborate with clinicians to gauge the quality of EMR data used to drive CDS and clinicians' receptivity to CDS, illuminate the sociotechnical context in which to deploy the CDS, and champion the CDS intervention among their colleagues. Clinicians' input is therefore an essential ingredient to success. Fourth, organizational trust, a key aspect of a healthy safety culture, is hard to build and easy to erode.[9, 16] If clinicians at an organization lose trust in CDS because of poor design and deployment strategies, they are likely to ignore CDS in the future.[17]

Like tools introduced into medicine such as magnetic resonance imaging and highly active antiretroviral therapy, CDS will need to evolve as the clinical community grapples with its potential and limitations. As EMRs move toward ubiquity in the hospital setting, CDS will become part of the fabric of hospital‐based practice, and the Journal of Hospital Medicine readership would do well to learn about this new tool of the trade.

The adoption of electronic health records (EHRs) in US hospitals continues to rise steeply, with nearly 60% of all hospitals having at least a basic EHR as of 2014.[1] EHRs bring with them the ability to inform and guide clinicians as they make decisions. In theory, this form of clinical decision support (CDS) ensures quality of care, reduces adverse events, and improves efficiency; in practice, experience in the field paints a mixed picture.[2, 3] This issue of the Journal of Hospital Medicine presents 3 examples of CDS that illustrate the distance between what we see as CDS' full potential and current limitations.

In the study by Herzig et al.[4] investigators took on the challenge of implementing stress ulcer prophylaxis guidelines developed by the Society of Hospital Medicine. The investigators first demonstrated that targeted electronic prompts captured patients' indications for acid suppressive therapy, and could be used to prohibit prescribers from ordering acid suppressive therapy among patients outside the intensive care unit (ICU) setting. Through an elegant interrupted time series study design deployed across 2 hospital campuses, the investigators were able to demonstrate immediate and clinically significant reduction in acid suppressive therapy outside the ICU. They further found that the impact of this reduction was augmented over time, suggesting that the electronic prompts had a sustained impact on provider ordering behavior. However, below the headlineand relevant to the limitations of CDSthe investigators noted that much of the reduction in the use of acid suppressive therapy for stress ulcer prophylaxis could be accounted for by providers' choice of another acceptable indication (eg, continuing preadmission medication). The authors speculated that the CDS intervention prompted providers to more accurately record the indication for acid suppressive therapy. It is also possible that providers simply chose an alternate indication to circumvent the decision‐support step. Perhaps as a result of these 2 offsetting factors, the actual use of acid suppressive therapy, regardless of indication, only decreased in a modest and statistically nonsignificant way, casting the true effectiveness of this CDS intervention into question.

Two other studies in this issue of the Journal of Hospital Medicine[5, 6] provide valuable insights into interactions between social and technical factors[7, 8, 9, 10] that determine the success or failure in the use of technology such as CDS to drive organizational performance. At the technical end of this sociotechnical spectrum, the study by Knight et al.[5] illustrated that a minimally configured and visually unintuitive medication decision‐support system resulted in a high number of alerts (approximately 17% of studied orders), leading to the well‐reported phenomena of alert fatigue and substantially lower response rate compared to those reported in the literature.[11, 12, 13] Moreover, the analysis suggested that response to these alerts were particularly muted among situations that were particularly high risk, including the patient being older, patient having a greater length of stay, care being delivered in the internal medicine service, resident physician being the prescriber, and the medication being on the Institute for Safe Medication Practices list of high‐alert medications. The investigators concluded that a redesign of the medication decision‐support system was needed.

The study by Chen et al.[6] illuminated how social factors pose challenges in implementing CDS. Investigators in this study were previously successful in using a combination of an education campaign and interruptive decision‐support prompts to reduce the inappropriate ordering of blood transfusions. However, even with a successful intervention, up to 30% of transfusions occurred outside of recommended guidelines. This finding prompted the investigators to analyze the free‐text reasons offered by providers for overriding the recommended guidelines. Two key patterns emerged from their structured analysis. First, many of the apparently inappropriate transfusions occurred under officially sanctioned protocols (such as stem cell transplant) that the computer system was not able to take into account in generating alerts. Second, many orders that reflected questionable practices were being entered by resident physicians, physician assistants, nurse practitioners, and nurses who were least empowered to challenge requests from senior staff.

Several practical and actionable lessons can be drawn from the 3 sets of investigators featured in this issue of the Journal of Hospital Medicine. First, all investigators defined metrics that should be tracked over time to demonstrate progress and to make iterative improvements; this discipline is needed in both academic and community settings to prioritize limited CDS resources in an objective and data‐driven way. Second, as the Herzig et al.[4] article illustrated, when it comes to evaluating the impact of CDS, we cannot be satisfied merely with process measures (eg, change in clinical documentation) at the expense of outcome measures (eg, decrease in inappropriate use of therapies). Third, as Chen et al.[6] recognized, CDS is but a component of an educational program to guide and alter clinical behavior, and must be deployed in conjunction with other educational tools such as newsletters, traditional lectures, or academic detailing. Fourth, clinicians with a stake in improving quality and safety should be on guard against the well‐documented phenomena of alert fatigue by ensuring their organization selects an appropriate framework for deciding which CDS alerts are activated andwhere possibledisplay the highest‐priority alerts in the most prominent and interruptive manner. Fifth, CDS must be maintained over time as clinical guidelines and clinicians' receptivity to each CDS evolve. Alerts that are not changing clinical behavior should either be modified or simply turned off. Sixth, free text entered as part of structured data entry (eg, while placing orders) or as reasons for overriding CDS (as in Chen et al.[6]) offer significant insights on how to optimize CDS, and should be monitored systematically on an ongoing basis to ensure the EMR addresses users' changing needs and mental models.

So what is the clinician with an interest in improving healthcare outcomes and organizational efficiency to do given CDS' limitations? One option is to wait for the science of CDS to further mature and have those advances embedded in the EMR at your organization. Another option might be to rely on the information technology and clinical informatics professionals at your organization to decide how CDS should be used locally. In 2014, these may be untenable choices for the following reasons. First, given the universal pressures to improve healthcare outcomes and contain costs,[14] healthcare organizations must use all available tools to achieve challenging performance goals. Second, as EMRs with CDS become commonplace, and as the 3 articles in this issue of the Journal of Hospital Medicine and others have illustrated, there are many opportunities to misuse or poorly implement CDS, with potentially dire consequences.[15] Third, design and deployment of effective CDS require information technology and informatics professionals to collaborate with clinicians to gauge the quality of EMR data used to drive CDS and clinicians' receptivity to CDS, illuminate the sociotechnical context in which to deploy the CDS, and champion the CDS intervention among their colleagues. Clinicians' input is therefore an essential ingredient to success. Fourth, organizational trust, a key aspect of a healthy safety culture, is hard to build and easy to erode.[9, 16] If clinicians at an organization lose trust in CDS because of poor design and deployment strategies, they are likely to ignore CDS in the future.[17]

Like tools introduced into medicine such as magnetic resonance imaging and highly active antiretroviral therapy, CDS will need to evolve as the clinical community grapples with its potential and limitations. As EMRs move toward ubiquity in the hospital setting, CDS will become part of the fabric of hospital‐based practice, and the Journal of Hospital Medicine readership would do well to learn about this new tool of the trade.

The adoption of electronic health records (EHRs) in US hospitals continues to rise steeply, with nearly 60% of all hospitals having at least a basic EHR as of 2014.[1] EHRs bring with them the ability to inform and guide clinicians as they make decisions. In theory, this form of clinical decision support (CDS) ensures quality of care, reduces adverse events, and improves efficiency; in practice, experience in the field paints a mixed picture.[2, 3] This issue of the Journal of Hospital Medicine presents 3 examples of CDS that illustrate the distance between what we see as CDS' full potential and current limitations.

In the study by Herzig et al.[4] investigators took on the challenge of implementing stress ulcer prophylaxis guidelines developed by the Society of Hospital Medicine. The investigators first demonstrated that targeted electronic prompts captured patients' indications for acid suppressive therapy, and could be used to prohibit prescribers from ordering acid suppressive therapy among patients outside the intensive care unit (ICU) setting. Through an elegant interrupted time series study design deployed across 2 hospital campuses, the investigators were able to demonstrate immediate and clinically significant reduction in acid suppressive therapy outside the ICU. They further found that the impact of this reduction was augmented over time, suggesting that the electronic prompts had a sustained impact on provider ordering behavior. However, below the headlineand relevant to the limitations of CDSthe investigators noted that much of the reduction in the use of acid suppressive therapy for stress ulcer prophylaxis could be accounted for by providers' choice of another acceptable indication (eg, continuing preadmission medication). The authors speculated that the CDS intervention prompted providers to more accurately record the indication for acid suppressive therapy. It is also possible that providers simply chose an alternate indication to circumvent the decision‐support step. Perhaps as a result of these 2 offsetting factors, the actual use of acid suppressive therapy, regardless of indication, only decreased in a modest and statistically nonsignificant way, casting the true effectiveness of this CDS intervention into question.

Two other studies in this issue of the Journal of Hospital Medicine[5, 6] provide valuable insights into interactions between social and technical factors[7, 8, 9, 10] that determine the success or failure in the use of technology such as CDS to drive organizational performance. At the technical end of this sociotechnical spectrum, the study by Knight et al.[5] illustrated that a minimally configured and visually unintuitive medication decision‐support system resulted in a high number of alerts (approximately 17% of studied orders), leading to the well‐reported phenomena of alert fatigue and substantially lower response rate compared to those reported in the literature.[11, 12, 13] Moreover, the analysis suggested that response to these alerts were particularly muted among situations that were particularly high risk, including the patient being older, patient having a greater length of stay, care being delivered in the internal medicine service, resident physician being the prescriber, and the medication being on the Institute for Safe Medication Practices list of high‐alert medications. The investigators concluded that a redesign of the medication decision‐support system was needed.

The study by Chen et al.[6] illuminated how social factors pose challenges in implementing CDS. Investigators in this study were previously successful in using a combination of an education campaign and interruptive decision‐support prompts to reduce the inappropriate ordering of blood transfusions. However, even with a successful intervention, up to 30% of transfusions occurred outside of recommended guidelines. This finding prompted the investigators to analyze the free‐text reasons offered by providers for overriding the recommended guidelines. Two key patterns emerged from their structured analysis. First, many of the apparently inappropriate transfusions occurred under officially sanctioned protocols (such as stem cell transplant) that the computer system was not able to take into account in generating alerts. Second, many orders that reflected questionable practices were being entered by resident physicians, physician assistants, nurse practitioners, and nurses who were least empowered to challenge requests from senior staff.

Several practical and actionable lessons can be drawn from the 3 sets of investigators featured in this issue of the Journal of Hospital Medicine. First, all investigators defined metrics that should be tracked over time to demonstrate progress and to make iterative improvements; this discipline is needed in both academic and community settings to prioritize limited CDS resources in an objective and data‐driven way. Second, as the Herzig et al.[4] article illustrated, when it comes to evaluating the impact of CDS, we cannot be satisfied merely with process measures (eg, change in clinical documentation) at the expense of outcome measures (eg, decrease in inappropriate use of therapies). Third, as Chen et al.[6] recognized, CDS is but a component of an educational program to guide and alter clinical behavior, and must be deployed in conjunction with other educational tools such as newsletters, traditional lectures, or academic detailing. Fourth, clinicians with a stake in improving quality and safety should be on guard against the well‐documented phenomena of alert fatigue by ensuring their organization selects an appropriate framework for deciding which CDS alerts are activated andwhere possibledisplay the highest‐priority alerts in the most prominent and interruptive manner. Fifth, CDS must be maintained over time as clinical guidelines and clinicians' receptivity to each CDS evolve. Alerts that are not changing clinical behavior should either be modified or simply turned off. Sixth, free text entered as part of structured data entry (eg, while placing orders) or as reasons for overriding CDS (as in Chen et al.[6]) offer significant insights on how to optimize CDS, and should be monitored systematically on an ongoing basis to ensure the EMR addresses users' changing needs and mental models.

So what is the clinician with an interest in improving healthcare outcomes and organizational efficiency to do given CDS' limitations? One option is to wait for the science of CDS to further mature and have those advances embedded in the EMR at your organization. Another option might be to rely on the information technology and clinical informatics professionals at your organization to decide how CDS should be used locally. In 2014, these may be untenable choices for the following reasons. First, given the universal pressures to improve healthcare outcomes and contain costs,[14] healthcare organizations must use all available tools to achieve challenging performance goals. Second, as EMRs with CDS become commonplace, and as the 3 articles in this issue of the Journal of Hospital Medicine and others have illustrated, there are many opportunities to misuse or poorly implement CDS, with potentially dire consequences.[15] Third, design and deployment of effective CDS require information technology and informatics professionals to collaborate with clinicians to gauge the quality of EMR data used to drive CDS and clinicians' receptivity to CDS, illuminate the sociotechnical context in which to deploy the CDS, and champion the CDS intervention among their colleagues. Clinicians' input is therefore an essential ingredient to success. Fourth, organizational trust, a key aspect of a healthy safety culture, is hard to build and easy to erode.[9, 16] If clinicians at an organization lose trust in CDS because of poor design and deployment strategies, they are likely to ignore CDS in the future.[17]

Like tools introduced into medicine such as magnetic resonance imaging and highly active antiretroviral therapy, CDS will need to evolve as the clinical community grapples with its potential and limitations. As EMRs move toward ubiquity in the hospital setting, CDS will become part of the fabric of hospital‐based practice, and the Journal of Hospital Medicine readership would do well to learn about this new tool of the trade.

Patients who are hospitalized for an acute event often have a range of prior outpatient experiences within the healthcare system, both before and after a hospitalization. In particular, continuity with a primary care provider can influence health outcomes.[1] In this issue of the Journal of Hospital Medicine, Boonyasai et al. found several characteristics of primary care physicians that were associated with whether their hospitalized patients were cared for by hospitalists.[2] Using Medicare claims data from the state of Texas during years 2001 to 2009, the authors calculated the percent of primary care physicians' hospitalized patients who were cared for by hospitalists. Hospitalist use increased overall during the time period, but primary care physicians differed in the rate and extent of hospitalist use. A minority of physicians were early adopters, with the majority of their hospitalized patients cared for by hospitalists during the entire time period. A sizeable group of primary care physicians mostly avoided using hospitalists. Moreover, there was a significant cluster of primary care physicians who, at some point during the study period, rapidly began using hospitalists within a relatively short time.

Several physician characteristics were associated with a greater adoption of the hospitalist model, including being female, in a family practice specialty, or in a rural practice setting. What this study lacks is the ability to explain why some physicians used hospitalists and others did not. It is probable that adoption (or not) of hospitalists is less an individual physician decision and instead reflects a choice of their clinical practice group. If an outpatient practice group or provider can influence whether or not their patients are cared for by hospitalists, it is also conceivable that they can affect hospital‐based outcomes as well. This finding reinforces the importance of examining the care and outcomes of patient care across the continuum of care, rather than focusing on the inpatient or outpatient setting.

As a result of the Affordable Care Act and rising healthcare costs, provider groups are beginning to form accountable care organizations (ACOs). An ACO is partnership between payers and providers to care for a population of patients across the continuum of care. In these arrangements, the providers often take on financial risk for the total cost of care for a population as well as for providing high‐quality care as monitored by specific metrics.[3] The population of patients for which ACOs take risks often include predominantly patients who receive primary care from the group.[4] For overall cost management, given that acute hospitalizations are disproportionately high cost, a primary focus of a majority of ACOs is to reduce unnecessary hospital days. Overall, ACOs that have been successful in the short term in managing costs have done so primarily by reducing overall hospital days.[5] ACOs have started to do so by creating intensive outpatient care management programs for high‐risk patients, by focusing on transitions of care to help decrease readmissions, by working with primary care clinics to transform into patient‐centered medical homes, where same‐day access to care is a priority, and developing other disease‐management tools to keep patients healthy.

To manage hospital utilization, many ACOs have developed plans to transform primary care and shift hospital care to outpatient care through enhanced outpatient case management for complex cases. As the way primary care is delivered changes, it will be very important to understand how this will modify the utilization and impact of hospitalist care on patients. The hope is that these modifications will work synergistically with hospitalist programs.

As the lines between outpatient and inpatient care become increasingly blurred, it may not be fair to attribute hospitalization outcome measures to hospitalists alone, particularly as ACOs are likely to move only the sickest or most difficult to manage patients to the inpatient setting. This may affect hospital‐based quality metrics such as readmissions and mortality. Seamless communication and transfer of information between outpatient and inpatient care will be vital to the success of ACOs.[6] In addition to improved communication, however, some systems may look to hospitalists to staff postdischarge clinics or act as extensivists or ambulatory intensivists to help manage the sickest in the population.[7]

Boonyasi et al. show that primary care physician characteristics as associated with whether or not patients' receive care from hospitalists.[2] As such, it reinforces the concept that providers in part of the continuum of care are integrally tied to care received by patients in different treatment settings. As our healthcare system rapidly transforms over the next few years, it will become more important to understand how outpatient and inpatient providers influence one another's care patterns and how these relationships influence care and cost‐related outcomes for patients.

Patients who are hospitalized for an acute event often have a range of prior outpatient experiences within the healthcare system, both before and after a hospitalization. In particular, continuity with a primary care provider can influence health outcomes.[1] In this issue of the Journal of Hospital Medicine, Boonyasai et al. found several characteristics of primary care physicians that were associated with whether their hospitalized patients were cared for by hospitalists.[2] Using Medicare claims data from the state of Texas during years 2001 to 2009, the authors calculated the percent of primary care physicians' hospitalized patients who were cared for by hospitalists. Hospitalist use increased overall during the time period, but primary care physicians differed in the rate and extent of hospitalist use. A minority of physicians were early adopters, with the majority of their hospitalized patients cared for by hospitalists during the entire time period. A sizeable group of primary care physicians mostly avoided using hospitalists. Moreover, there was a significant cluster of primary care physicians who, at some point during the study period, rapidly began using hospitalists within a relatively short time.

Several physician characteristics were associated with a greater adoption of the hospitalist model, including being female, in a family practice specialty, or in a rural practice setting. What this study lacks is the ability to explain why some physicians used hospitalists and others did not. It is probable that adoption (or not) of hospitalists is less an individual physician decision and instead reflects a choice of their clinical practice group. If an outpatient practice group or provider can influence whether or not their patients are cared for by hospitalists, it is also conceivable that they can affect hospital‐based outcomes as well. This finding reinforces the importance of examining the care and outcomes of patient care across the continuum of care, rather than focusing on the inpatient or outpatient setting.

As a result of the Affordable Care Act and rising healthcare costs, provider groups are beginning to form accountable care organizations (ACOs). An ACO is partnership between payers and providers to care for a population of patients across the continuum of care. In these arrangements, the providers often take on financial risk for the total cost of care for a population as well as for providing high‐quality care as monitored by specific metrics.[3] The population of patients for which ACOs take risks often include predominantly patients who receive primary care from the group.[4] For overall cost management, given that acute hospitalizations are disproportionately high cost, a primary focus of a majority of ACOs is to reduce unnecessary hospital days. Overall, ACOs that have been successful in the short term in managing costs have done so primarily by reducing overall hospital days.[5] ACOs have started to do so by creating intensive outpatient care management programs for high‐risk patients, by focusing on transitions of care to help decrease readmissions, by working with primary care clinics to transform into patient‐centered medical homes, where same‐day access to care is a priority, and developing other disease‐management tools to keep patients healthy.

To manage hospital utilization, many ACOs have developed plans to transform primary care and shift hospital care to outpatient care through enhanced outpatient case management for complex cases. As the way primary care is delivered changes, it will be very important to understand how this will modify the utilization and impact of hospitalist care on patients. The hope is that these modifications will work synergistically with hospitalist programs.

As the lines between outpatient and inpatient care become increasingly blurred, it may not be fair to attribute hospitalization outcome measures to hospitalists alone, particularly as ACOs are likely to move only the sickest or most difficult to manage patients to the inpatient setting. This may affect hospital‐based quality metrics such as readmissions and mortality. Seamless communication and transfer of information between outpatient and inpatient care will be vital to the success of ACOs.[6] In addition to improved communication, however, some systems may look to hospitalists to staff postdischarge clinics or act as extensivists or ambulatory intensivists to help manage the sickest in the population.[7]

Boonyasi et al. show that primary care physician characteristics as associated with whether or not patients' receive care from hospitalists.[2] As such, it reinforces the concept that providers in part of the continuum of care are integrally tied to care received by patients in different treatment settings. As our healthcare system rapidly transforms over the next few years, it will become more important to understand how outpatient and inpatient providers influence one another's care patterns and how these relationships influence care and cost‐related outcomes for patients.

Patients who are hospitalized for an acute event often have a range of prior outpatient experiences within the healthcare system, both before and after a hospitalization. In particular, continuity with a primary care provider can influence health outcomes.[1] In this issue of the Journal of Hospital Medicine, Boonyasai et al. found several characteristics of primary care physicians that were associated with whether their hospitalized patients were cared for by hospitalists.[2] Using Medicare claims data from the state of Texas during years 2001 to 2009, the authors calculated the percent of primary care physicians' hospitalized patients who were cared for by hospitalists. Hospitalist use increased overall during the time period, but primary care physicians differed in the rate and extent of hospitalist use. A minority of physicians were early adopters, with the majority of their hospitalized patients cared for by hospitalists during the entire time period. A sizeable group of primary care physicians mostly avoided using hospitalists. Moreover, there was a significant cluster of primary care physicians who, at some point during the study period, rapidly began using hospitalists within a relatively short time.

Several physician characteristics were associated with a greater adoption of the hospitalist model, including being female, in a family practice specialty, or in a rural practice setting. What this study lacks is the ability to explain why some physicians used hospitalists and others did not. It is probable that adoption (or not) of hospitalists is less an individual physician decision and instead reflects a choice of their clinical practice group. If an outpatient practice group or provider can influence whether or not their patients are cared for by hospitalists, it is also conceivable that they can affect hospital‐based outcomes as well. This finding reinforces the importance of examining the care and outcomes of patient care across the continuum of care, rather than focusing on the inpatient or outpatient setting.

As a result of the Affordable Care Act and rising healthcare costs, provider groups are beginning to form accountable care organizations (ACOs). An ACO is partnership between payers and providers to care for a population of patients across the continuum of care. In these arrangements, the providers often take on financial risk for the total cost of care for a population as well as for providing high‐quality care as monitored by specific metrics.[3] The population of patients for which ACOs take risks often include predominantly patients who receive primary care from the group.[4] For overall cost management, given that acute hospitalizations are disproportionately high cost, a primary focus of a majority of ACOs is to reduce unnecessary hospital days. Overall, ACOs that have been successful in the short term in managing costs have done so primarily by reducing overall hospital days.[5] ACOs have started to do so by creating intensive outpatient care management programs for high‐risk patients, by focusing on transitions of care to help decrease readmissions, by working with primary care clinics to transform into patient‐centered medical homes, where same‐day access to care is a priority, and developing other disease‐management tools to keep patients healthy.

To manage hospital utilization, many ACOs have developed plans to transform primary care and shift hospital care to outpatient care through enhanced outpatient case management for complex cases. As the way primary care is delivered changes, it will be very important to understand how this will modify the utilization and impact of hospitalist care on patients. The hope is that these modifications will work synergistically with hospitalist programs.

As the lines between outpatient and inpatient care become increasingly blurred, it may not be fair to attribute hospitalization outcome measures to hospitalists alone, particularly as ACOs are likely to move only the sickest or most difficult to manage patients to the inpatient setting. This may affect hospital‐based quality metrics such as readmissions and mortality. Seamless communication and transfer of information between outpatient and inpatient care will be vital to the success of ACOs.[6] In addition to improved communication, however, some systems may look to hospitalists to staff postdischarge clinics or act as extensivists or ambulatory intensivists to help manage the sickest in the population.[7]

Boonyasi et al. show that primary care physician characteristics as associated with whether or not patients' receive care from hospitalists.[2] As such, it reinforces the concept that providers in part of the continuum of care are integrally tied to care received by patients in different treatment settings. As our healthcare system rapidly transforms over the next few years, it will become more important to understand how outpatient and inpatient providers influence one another's care patterns and how these relationships influence care and cost‐related outcomes for patients.

In 2015, the Journal of Hospital Medicine will be publishing its 10th volume, marking an important milestone for hospital medicine. The journal has survived an early period where the need for and viability of an academic hospital medicine journal was not at all clear. More to the point, the Journal of Hospital Medicine has prospered and grown.

The journal continues to evolve as hospital medicine grows and changes. When the Journal of Hospital Medicine began, there was no particular focus on readmissions, ‐blockers were important to reduce perioperative risk, and tight glucose control was thought to be a critical goal for hospitalized patients. Evidence for hospitalists' effectiveness was also changing; initial evidence supporting uniform improvements in length of stay and possible improvement in outcomes were soon tempered by larger‐scale studies.

Clearly, things have changed in medicine writ large, and hospital medicine has changed and caused things to be changed as well. We now exist in a world of value‐based purchasing, accountable care, long‐overdue focus on patient‐centered care (and research), and all in a healthcare setting that is increasingly electronic in nature. Although healthcare delivery has changed, hospital medicine has retained critical core values, including our specialty's focus on interdisciplinary care, quality improvement, and safety.

The Journal of Hospital Medicine has been active in reflecting the field of hospital medicine since the journal began. Due in no small part to the vision of the field's leaders and the exertion and vision of the Journal of Hospital Medicine's founding editor, Mark Williams, the journal is a vigorous and important contributor to academic internal medicine. It has gone from 6 issues per year to 12 issues, has rapidly expanded the number of downloads and citations, and its impact in the field of medicine continues to grow.

When reflecting on the words most often used in the Journal of Hospital Medicine's article titles (Figure 1) over the last 9 volumes, we were not surprised to see that the words hospital and hospitalists figured prominently. However, we were more pleased to see that the words patient and care were a large part of the universe of the Journal of Hospital Medicine's article titles.

Figure 1

The Journal of Hospital Medicine's articles are also being read and cited more and more often. The top 10 most downloaded articles are ones that represent a wide range of topics of clinical and operational importance to the field (Table 1), and the 10 most cited articles (Table 2) represent how the scholarship being produced by the field of hospital medicine is being used to advance other scientific and policy initiatives. Only 1 article[1] was listed in both places, demonstrating the difference between what the Journal of Hospital Medicine publishes as a way to help hospitalists provide better care on a day‐to‐day basis and what the journal publishes to advance the field.

Our 10th volume will continue the work of promoting scholarship and inquiry in hospital medicine by retaining a clear focus on the science that represents the best of an intellectual agenda[2] for our field. To achieve this important goal, the Journal of Hospital Medicine and the field will need to develop durable evidence for not only how hospitalists deliver care, but also evidence for how care can be improved by providing better treatments. Stated differently, hospitalists and the Journal of Hospital Medicine will need to be focused not only on improving the healthcare system, but also on evaluating new technologies, drugs, and devices that can be used in a value‐focused health system.

In 2015, the Journal of Hospital Medicine will also be launching a new series focusing on improving healthcare value. Titled Choosing Wisely: Next Steps in Improving Healthcare Value, this series of invited reviews will cover important topics needed to frame approaches to reducing healthcare costs while improving care quality and safety. This American Board of Internal Medicine‐sponsored series will be accompanied by a parallel series titled Things We Do for No Reason. Things We Do will provide a series of case studies of tests, medications, or procedures hospitalists encounter every day. We hope these topics, along with the Society of Hospital Medicine's Choosing Wisely focus areas, will continue to outline useful opportunities to improve healthcare value at the bedside or at least frame what we expect will be a lively debate.

We are confident that the combination of highest‐quality peer review and new article offerings will only enhance our ability to share the highest‐quality research, perspectives, reviews, and clinical cases and conundrums with Journal of Hospital Medicine readers. The journal's editors and I look forward to this new year, the Journal of Hospital Medicine's 10th volume, and to many volumes of the Journal of Hospital Medicine to come.

In 2015, the Journal of Hospital Medicine will be publishing its 10th volume, marking an important milestone for hospital medicine. The journal has survived an early period where the need for and viability of an academic hospital medicine journal was not at all clear. More to the point, the Journal of Hospital Medicine has prospered and grown.

The journal continues to evolve as hospital medicine grows and changes. When the Journal of Hospital Medicine began, there was no particular focus on readmissions, ‐blockers were important to reduce perioperative risk, and tight glucose control was thought to be a critical goal for hospitalized patients. Evidence for hospitalists' effectiveness was also changing; initial evidence supporting uniform improvements in length of stay and possible improvement in outcomes were soon tempered by larger‐scale studies.

Clearly, things have changed in medicine writ large, and hospital medicine has changed and caused things to be changed as well. We now exist in a world of value‐based purchasing, accountable care, long‐overdue focus on patient‐centered care (and research), and all in a healthcare setting that is increasingly electronic in nature. Although healthcare delivery has changed, hospital medicine has retained critical core values, including our specialty's focus on interdisciplinary care, quality improvement, and safety.

The Journal of Hospital Medicine has been active in reflecting the field of hospital medicine since the journal began. Due in no small part to the vision of the field's leaders and the exertion and vision of the Journal of Hospital Medicine's founding editor, Mark Williams, the journal is a vigorous and important contributor to academic internal medicine. It has gone from 6 issues per year to 12 issues, has rapidly expanded the number of downloads and citations, and its impact in the field of medicine continues to grow.

When reflecting on the words most often used in the Journal of Hospital Medicine's article titles (Figure 1) over the last 9 volumes, we were not surprised to see that the words hospital and hospitalists figured prominently. However, we were more pleased to see that the words patient and care were a large part of the universe of the Journal of Hospital Medicine's article titles.

Figure 1

The Journal of Hospital Medicine's articles are also being read and cited more and more often. The top 10 most downloaded articles are ones that represent a wide range of topics of clinical and operational importance to the field (Table 1), and the 10 most cited articles (Table 2) represent how the scholarship being produced by the field of hospital medicine is being used to advance other scientific and policy initiatives. Only 1 article[1] was listed in both places, demonstrating the difference between what the Journal of Hospital Medicine publishes as a way to help hospitalists provide better care on a day‐to‐day basis and what the journal publishes to advance the field.

Our 10th volume will continue the work of promoting scholarship and inquiry in hospital medicine by retaining a clear focus on the science that represents the best of an intellectual agenda[2] for our field. To achieve this important goal, the Journal of Hospital Medicine and the field will need to develop durable evidence for not only how hospitalists deliver care, but also evidence for how care can be improved by providing better treatments. Stated differently, hospitalists and the Journal of Hospital Medicine will need to be focused not only on improving the healthcare system, but also on evaluating new technologies, drugs, and devices that can be used in a value‐focused health system.

In 2015, the Journal of Hospital Medicine will also be launching a new series focusing on improving healthcare value. Titled Choosing Wisely: Next Steps in Improving Healthcare Value, this series of invited reviews will cover important topics needed to frame approaches to reducing healthcare costs while improving care quality and safety. This American Board of Internal Medicine‐sponsored series will be accompanied by a parallel series titled Things We Do for No Reason. Things We Do will provide a series of case studies of tests, medications, or procedures hospitalists encounter every day. We hope these topics, along with the Society of Hospital Medicine's Choosing Wisely focus areas, will continue to outline useful opportunities to improve healthcare value at the bedside or at least frame what we expect will be a lively debate.

We are confident that the combination of highest‐quality peer review and new article offerings will only enhance our ability to share the highest‐quality research, perspectives, reviews, and clinical cases and conundrums with Journal of Hospital Medicine readers. The journal's editors and I look forward to this new year, the Journal of Hospital Medicine's 10th volume, and to many volumes of the Journal of Hospital Medicine to come.

In 2015, the Journal of Hospital Medicine will be publishing its 10th volume, marking an important milestone for hospital medicine. The journal has survived an early period where the need for and viability of an academic hospital medicine journal was not at all clear. More to the point, the Journal of Hospital Medicine has prospered and grown.

The journal continues to evolve as hospital medicine grows and changes. When the Journal of Hospital Medicine began, there was no particular focus on readmissions, ‐blockers were important to reduce perioperative risk, and tight glucose control was thought to be a critical goal for hospitalized patients. Evidence for hospitalists' effectiveness was also changing; initial evidence supporting uniform improvements in length of stay and possible improvement in outcomes were soon tempered by larger‐scale studies.

Clearly, things have changed in medicine writ large, and hospital medicine has changed and caused things to be changed as well. We now exist in a world of value‐based purchasing, accountable care, long‐overdue focus on patient‐centered care (and research), and all in a healthcare setting that is increasingly electronic in nature. Although healthcare delivery has changed, hospital medicine has retained critical core values, including our specialty's focus on interdisciplinary care, quality improvement, and safety.

The Journal of Hospital Medicine has been active in reflecting the field of hospital medicine since the journal began. Due in no small part to the vision of the field's leaders and the exertion and vision of the Journal of Hospital Medicine's founding editor, Mark Williams, the journal is a vigorous and important contributor to academic internal medicine. It has gone from 6 issues per year to 12 issues, has rapidly expanded the number of downloads and citations, and its impact in the field of medicine continues to grow.

When reflecting on the words most often used in the Journal of Hospital Medicine's article titles (Figure 1) over the last 9 volumes, we were not surprised to see that the words hospital and hospitalists figured prominently. However, we were more pleased to see that the words patient and care were a large part of the universe of the Journal of Hospital Medicine's article titles.

Figure 1

The Journal of Hospital Medicine's articles are also being read and cited more and more often. The top 10 most downloaded articles are ones that represent a wide range of topics of clinical and operational importance to the field (Table 1), and the 10 most cited articles (Table 2) represent how the scholarship being produced by the field of hospital medicine is being used to advance other scientific and policy initiatives. Only 1 article[1] was listed in both places, demonstrating the difference between what the Journal of Hospital Medicine publishes as a way to help hospitalists provide better care on a day‐to‐day basis and what the journal publishes to advance the field.

Our 10th volume will continue the work of promoting scholarship and inquiry in hospital medicine by retaining a clear focus on the science that represents the best of an intellectual agenda[2] for our field. To achieve this important goal, the Journal of Hospital Medicine and the field will need to develop durable evidence for not only how hospitalists deliver care, but also evidence for how care can be improved by providing better treatments. Stated differently, hospitalists and the Journal of Hospital Medicine will need to be focused not only on improving the healthcare system, but also on evaluating new technologies, drugs, and devices that can be used in a value‐focused health system.

In 2015, the Journal of Hospital Medicine will also be launching a new series focusing on improving healthcare value. Titled Choosing Wisely: Next Steps in Improving Healthcare Value, this series of invited reviews will cover important topics needed to frame approaches to reducing healthcare costs while improving care quality and safety. This American Board of Internal Medicine‐sponsored series will be accompanied by a parallel series titled Things We Do for No Reason. Things We Do will provide a series of case studies of tests, medications, or procedures hospitalists encounter every day. We hope these topics, along with the Society of Hospital Medicine's Choosing Wisely focus areas, will continue to outline useful opportunities to improve healthcare value at the bedside or at least frame what we expect will be a lively debate.

We are confident that the combination of highest‐quality peer review and new article offerings will only enhance our ability to share the highest‐quality research, perspectives, reviews, and clinical cases and conundrums with Journal of Hospital Medicine readers. The journal's editors and I look forward to this new year, the Journal of Hospital Medicine's 10th volume, and to many volumes of the Journal of Hospital Medicine to come.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.