Editorial

Teamwork is tightly linked to patient safety for hospitalized patients. Barriers to teamwork in hospital settings abound, including large team sizes and dynamic team membership because of the need to provide care 24 hours a day, 7 days a week. Team members are often dispersed across clinical service areas and care for multiple patients at the same time. Compounding the potential for these structural barriers to impede teamwork, professionals seldom receive any formal training to enhance teamwork skills, and students and trainees have relatively few interactions during their formative years with individuals outside of their own profession. In this issue of the Journal of Hospital Medicine, Tofil et al. describe the effect of a novel interprofessional training program to improve teamwork among medical and nursing students at the University of Alabama.[1] The curriculum included 4, 1‐hour simulation sessions and resulted in improved ratings of self‐efficacy with communication and teamwork attitudes. The authors report that the curriculum has continued and expanded to include other health professionals.

Beyond the short‐term results, the curriculum developed by Tofil and colleagues may have lasting effects on individual participants. Students, exposed to one another during a particularly impressionable period of their professional development, may develop better appreciation for the priorities, responsibilities, needs, and expertise of others. The experience may inoculate them from adopting unfavorable behaviors and attitudes that are common among practicing clinicians and comprise the hidden curriculum, which often undermines the goals of the formal curriculum.[2] An early, positive experience with other team members may be especially important for medical students, as physicians tend to be relatively unaware of deficiencies in interprofessional collaboration.[3]

Though undoubtedly valuable to the learners and contributing to our collective knowledge on the subject, the study by Tofil and colleagues includes limitations common to teamwork training curricula.[4] To make the potential of teamwork training a reality in improving patient outcomes, we must first revisit some key teamwork concepts and principles of curriculum development. Baker and colleagues define a team as consisting of 2 or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal.[5] For a team to be successful, individual team members must have specific knowledge, skills, and attitudes (ie, competencies).[6] For team training curricula to be successful, existing frameworks like TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) should be used to define learning objectives.[7] Because teamwork is largely behavioral and affective, simulation is the most appropriate instruction method. Simulation involves deliberate practice and expert feedback so that learners can iteratively enhance teamwork skills. Other instructional methods (eg, didactics, video observation and debriefing, brief role play without feedback) are too weak to be effective.

Importantly, Tofil and colleagues used an accepted teamwork framework to develop learning objectives, simulation as the instructional method, and an interprofessional team (ie, a physician, nurse, and an adult learning professional with simulation expertise) to perform simulation debriefings. However, for team training to achieve its full potential, leaders of future efforts need to aim for higher level outcomes. Positive reactions are encouraging, but what we really want to know is that learners truly adopted new skills and attitudes, applied them in real‐world clinical settings, and that patients benefited from them. These are high but achievable goals and absolutely necessary to advance the credibility of team training. Relatively few studies have evaluated the impact of team training on patient outcomes, and the available evidence is equivocal.[8, 9] The intensity and duration of deliberate practice during simulation exercises must be sufficient to change ingrained behaviors and to ensure transfer of enhanced skills to the clinical setting if our goal is to improve patient outcomes.

Leaders of future efforts must also develop innovative simulation exercises that reflect the real‐life challenges and contexts for medical teamwork including dispersion of team members, challenges of communication in hierarchical teams, and competing demands under increasing time pressure. Simulated communication events could include a nurse deciding whether and how to contact a physician not immediately present (and vice versa). Sessions should include interruptions and require participants to multitask to replicate the clinical environment. Notably, simulation exercises provide an opportunity for assessment using a behaviorally anchored rating scale, which is often impractical in real clinical settings because team members are seldom in the same place at the same time. Booster simulation sessions should be provided to ensure skills do not decay over time. In situ simulation (ie, simulation events in the real clinical setting) offers the ability to reveal latent conditions impeding the efficiency or quality of communication among team members.

Most importantly, simulation‐based teamwork training must be combined with system redesign and improvement. Enhanced communication skills will only go so far if team members never have a chance to use them. Leaders should work with their hospitals to remove systemic barriers to teamwork. Opportunities for improvement include geographic localization of physicians, assigning patients to nurses to maximize homogeneity of team members, optimizing interprofessional rounds, and leveraging information and communication technologies. Simulation training should be seen as a complement to these interventions rather than a substitute.

Challenges to teamwork are multifactorial and therefore require multifaceted interventions. Simulation is essential to enhance teamwork skills and attitudes. For efforts to translate into improved patient outcomes, leaders must use innovative approaches and combine simulation training with system redesign and improvement.

Teamwork is tightly linked to patient safety for hospitalized patients. Barriers to teamwork in hospital settings abound, including large team sizes and dynamic team membership because of the need to provide care 24 hours a day, 7 days a week. Team members are often dispersed across clinical service areas and care for multiple patients at the same time. Compounding the potential for these structural barriers to impede teamwork, professionals seldom receive any formal training to enhance teamwork skills, and students and trainees have relatively few interactions during their formative years with individuals outside of their own profession. In this issue of the Journal of Hospital Medicine, Tofil et al. describe the effect of a novel interprofessional training program to improve teamwork among medical and nursing students at the University of Alabama.[1] The curriculum included 4, 1‐hour simulation sessions and resulted in improved ratings of self‐efficacy with communication and teamwork attitudes. The authors report that the curriculum has continued and expanded to include other health professionals.

Beyond the short‐term results, the curriculum developed by Tofil and colleagues may have lasting effects on individual participants. Students, exposed to one another during a particularly impressionable period of their professional development, may develop better appreciation for the priorities, responsibilities, needs, and expertise of others. The experience may inoculate them from adopting unfavorable behaviors and attitudes that are common among practicing clinicians and comprise the hidden curriculum, which often undermines the goals of the formal curriculum.[2] An early, positive experience with other team members may be especially important for medical students, as physicians tend to be relatively unaware of deficiencies in interprofessional collaboration.[3]

Though undoubtedly valuable to the learners and contributing to our collective knowledge on the subject, the study by Tofil and colleagues includes limitations common to teamwork training curricula.[4] To make the potential of teamwork training a reality in improving patient outcomes, we must first revisit some key teamwork concepts and principles of curriculum development. Baker and colleagues define a team as consisting of 2 or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal.[5] For a team to be successful, individual team members must have specific knowledge, skills, and attitudes (ie, competencies).[6] For team training curricula to be successful, existing frameworks like TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) should be used to define learning objectives.[7] Because teamwork is largely behavioral and affective, simulation is the most appropriate instruction method. Simulation involves deliberate practice and expert feedback so that learners can iteratively enhance teamwork skills. Other instructional methods (eg, didactics, video observation and debriefing, brief role play without feedback) are too weak to be effective.

Importantly, Tofil and colleagues used an accepted teamwork framework to develop learning objectives, simulation as the instructional method, and an interprofessional team (ie, a physician, nurse, and an adult learning professional with simulation expertise) to perform simulation debriefings. However, for team training to achieve its full potential, leaders of future efforts need to aim for higher level outcomes. Positive reactions are encouraging, but what we really want to know is that learners truly adopted new skills and attitudes, applied them in real‐world clinical settings, and that patients benefited from them. These are high but achievable goals and absolutely necessary to advance the credibility of team training. Relatively few studies have evaluated the impact of team training on patient outcomes, and the available evidence is equivocal.[8, 9] The intensity and duration of deliberate practice during simulation exercises must be sufficient to change ingrained behaviors and to ensure transfer of enhanced skills to the clinical setting if our goal is to improve patient outcomes.

Leaders of future efforts must also develop innovative simulation exercises that reflect the real‐life challenges and contexts for medical teamwork including dispersion of team members, challenges of communication in hierarchical teams, and competing demands under increasing time pressure. Simulated communication events could include a nurse deciding whether and how to contact a physician not immediately present (and vice versa). Sessions should include interruptions and require participants to multitask to replicate the clinical environment. Notably, simulation exercises provide an opportunity for assessment using a behaviorally anchored rating scale, which is often impractical in real clinical settings because team members are seldom in the same place at the same time. Booster simulation sessions should be provided to ensure skills do not decay over time. In situ simulation (ie, simulation events in the real clinical setting) offers the ability to reveal latent conditions impeding the efficiency or quality of communication among team members.

Most importantly, simulation‐based teamwork training must be combined with system redesign and improvement. Enhanced communication skills will only go so far if team members never have a chance to use them. Leaders should work with their hospitals to remove systemic barriers to teamwork. Opportunities for improvement include geographic localization of physicians, assigning patients to nurses to maximize homogeneity of team members, optimizing interprofessional rounds, and leveraging information and communication technologies. Simulation training should be seen as a complement to these interventions rather than a substitute.

Challenges to teamwork are multifactorial and therefore require multifaceted interventions. Simulation is essential to enhance teamwork skills and attitudes. For efforts to translate into improved patient outcomes, leaders must use innovative approaches and combine simulation training with system redesign and improvement.

Teamwork is tightly linked to patient safety for hospitalized patients. Barriers to teamwork in hospital settings abound, including large team sizes and dynamic team membership because of the need to provide care 24 hours a day, 7 days a week. Team members are often dispersed across clinical service areas and care for multiple patients at the same time. Compounding the potential for these structural barriers to impede teamwork, professionals seldom receive any formal training to enhance teamwork skills, and students and trainees have relatively few interactions during their formative years with individuals outside of their own profession. In this issue of the Journal of Hospital Medicine, Tofil et al. describe the effect of a novel interprofessional training program to improve teamwork among medical and nursing students at the University of Alabama.[1] The curriculum included 4, 1‐hour simulation sessions and resulted in improved ratings of self‐efficacy with communication and teamwork attitudes. The authors report that the curriculum has continued and expanded to include other health professionals.

Beyond the short‐term results, the curriculum developed by Tofil and colleagues may have lasting effects on individual participants. Students, exposed to one another during a particularly impressionable period of their professional development, may develop better appreciation for the priorities, responsibilities, needs, and expertise of others. The experience may inoculate them from adopting unfavorable behaviors and attitudes that are common among practicing clinicians and comprise the hidden curriculum, which often undermines the goals of the formal curriculum.[2] An early, positive experience with other team members may be especially important for medical students, as physicians tend to be relatively unaware of deficiencies in interprofessional collaboration.[3]

Though undoubtedly valuable to the learners and contributing to our collective knowledge on the subject, the study by Tofil and colleagues includes limitations common to teamwork training curricula.[4] To make the potential of teamwork training a reality in improving patient outcomes, we must first revisit some key teamwork concepts and principles of curriculum development. Baker and colleagues define a team as consisting of 2 or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal.[5] For a team to be successful, individual team members must have specific knowledge, skills, and attitudes (ie, competencies).[6] For team training curricula to be successful, existing frameworks like TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) should be used to define learning objectives.[7] Because teamwork is largely behavioral and affective, simulation is the most appropriate instruction method. Simulation involves deliberate practice and expert feedback so that learners can iteratively enhance teamwork skills. Other instructional methods (eg, didactics, video observation and debriefing, brief role play without feedback) are too weak to be effective.

Importantly, Tofil and colleagues used an accepted teamwork framework to develop learning objectives, simulation as the instructional method, and an interprofessional team (ie, a physician, nurse, and an adult learning professional with simulation expertise) to perform simulation debriefings. However, for team training to achieve its full potential, leaders of future efforts need to aim for higher level outcomes. Positive reactions are encouraging, but what we really want to know is that learners truly adopted new skills and attitudes, applied them in real‐world clinical settings, and that patients benefited from them. These are high but achievable goals and absolutely necessary to advance the credibility of team training. Relatively few studies have evaluated the impact of team training on patient outcomes, and the available evidence is equivocal.[8, 9] The intensity and duration of deliberate practice during simulation exercises must be sufficient to change ingrained behaviors and to ensure transfer of enhanced skills to the clinical setting if our goal is to improve patient outcomes.

Leaders of future efforts must also develop innovative simulation exercises that reflect the real‐life challenges and contexts for medical teamwork including dispersion of team members, challenges of communication in hierarchical teams, and competing demands under increasing time pressure. Simulated communication events could include a nurse deciding whether and how to contact a physician not immediately present (and vice versa). Sessions should include interruptions and require participants to multitask to replicate the clinical environment. Notably, simulation exercises provide an opportunity for assessment using a behaviorally anchored rating scale, which is often impractical in real clinical settings because team members are seldom in the same place at the same time. Booster simulation sessions should be provided to ensure skills do not decay over time. In situ simulation (ie, simulation events in the real clinical setting) offers the ability to reveal latent conditions impeding the efficiency or quality of communication among team members.

Most importantly, simulation‐based teamwork training must be combined with system redesign and improvement. Enhanced communication skills will only go so far if team members never have a chance to use them. Leaders should work with their hospitals to remove systemic barriers to teamwork. Opportunities for improvement include geographic localization of physicians, assigning patients to nurses to maximize homogeneity of team members, optimizing interprofessional rounds, and leveraging information and communication technologies. Simulation training should be seen as a complement to these interventions rather than a substitute.

Challenges to teamwork are multifactorial and therefore require multifaceted interventions. Simulation is essential to enhance teamwork skills and attitudes. For efforts to translate into improved patient outcomes, leaders must use innovative approaches and combine simulation training with system redesign and improvement.

Hospitalists, and physicians in general, recognize the need for continuing medical education (CME) to update their knowledge and skills to provide the best possible care for patients. Interactive and personalized learning activities provide the most effective approaches for maintaining or improving physician competency.[1, 2] Despite guidelines that recommend a shift of CME from the traditional large lecture format to case‐based and highly interactive learning techniques,[3] this has been challenging to achieve in practice.

In this issue of the Journal of Hospital Medicine, Sehgal and collaborators at the University of California, San Francisco (UCSF) report innovative and highly appealing CME activity that provides a short, focused experience for the practicing hospitalist seeking to update his or her skills.[4] The UCSF Hospitalist Mini‐College (UHMC) embraced the principles for creation of effective CME by conducting needs assessment from community hospitalists and constructing a program that provides focused, interactive, small‐group, intensive experiences and then evaluating the experience to improve subsequent iterations of the Mini‐College. The UHMC immerses participants in a relatively intense experience that includes close interaction with prominent faculty, hands‐on bedside experiences, practical skills, and attendance at sessions (resident report, morbidity and mortality conferences) that are part of every resident trainee's experience. Participants would be linked to their previous learning activities. As the authors point out, there may be a powerful stimulus to learning when practicing physicians return to the milieu of training environments. This observation deserves further investigation.

The report does not provide evidence that participation in the Mini‐College improved patient outcomes or physician performance in practice; these outcome measures remain elusive and an aspirational goal in medical education research. However, experienced clinician educators have come to recognize and adopt effective interventions that simply make sense in the same fashion that it makes sense to use a parachute when jumping out of an airplane in flight.[5] The UHMC makes sense. The medical education literature is replete with articles describing educational innovations and their 1‐ to 2‐year outcomes, leaving the reader wondering about sustainability. It is reassuring that Sehgal et al. report 5 years of experience with the UHMC, and that the program has consistently had a waiting list of hospitalists who want to participate despite the expense. Although it requires patience on the part of educational innovators, this report helps set a standard for reporting enduring innovation in the education arena.

The article provides a description that is sufficiently detailed for other academic medical centers to replicate the intervention or to effectively adapt the principles of the intervention for the needs of their local hospitalist community. The authors should be congratulated for sharing the details of their program and for sharing powerful comments by participants. For hospitalist medical educators interested in sharing details of effective and sustained innovations, publication of this article emphasizes the Journal of Hospital Medicine's interest in disseminating these important projects.

In summary, the report on the UHMC model challenges all of us in academic hospital medicine to think creatively about how to provide effective, engaging, and exciting learning opportunities beyond the years of medical school and residency training.

Hospitalists, and physicians in general, recognize the need for continuing medical education (CME) to update their knowledge and skills to provide the best possible care for patients. Interactive and personalized learning activities provide the most effective approaches for maintaining or improving physician competency.[1, 2] Despite guidelines that recommend a shift of CME from the traditional large lecture format to case‐based and highly interactive learning techniques,[3] this has been challenging to achieve in practice.

In this issue of the Journal of Hospital Medicine, Sehgal and collaborators at the University of California, San Francisco (UCSF) report innovative and highly appealing CME activity that provides a short, focused experience for the practicing hospitalist seeking to update his or her skills.[4] The UCSF Hospitalist Mini‐College (UHMC) embraced the principles for creation of effective CME by conducting needs assessment from community hospitalists and constructing a program that provides focused, interactive, small‐group, intensive experiences and then evaluating the experience to improve subsequent iterations of the Mini‐College. The UHMC immerses participants in a relatively intense experience that includes close interaction with prominent faculty, hands‐on bedside experiences, practical skills, and attendance at sessions (resident report, morbidity and mortality conferences) that are part of every resident trainee's experience. Participants would be linked to their previous learning activities. As the authors point out, there may be a powerful stimulus to learning when practicing physicians return to the milieu of training environments. This observation deserves further investigation.

The report does not provide evidence that participation in the Mini‐College improved patient outcomes or physician performance in practice; these outcome measures remain elusive and an aspirational goal in medical education research. However, experienced clinician educators have come to recognize and adopt effective interventions that simply make sense in the same fashion that it makes sense to use a parachute when jumping out of an airplane in flight.[5] The UHMC makes sense. The medical education literature is replete with articles describing educational innovations and their 1‐ to 2‐year outcomes, leaving the reader wondering about sustainability. It is reassuring that Sehgal et al. report 5 years of experience with the UHMC, and that the program has consistently had a waiting list of hospitalists who want to participate despite the expense. Although it requires patience on the part of educational innovators, this report helps set a standard for reporting enduring innovation in the education arena.

The article provides a description that is sufficiently detailed for other academic medical centers to replicate the intervention or to effectively adapt the principles of the intervention for the needs of their local hospitalist community. The authors should be congratulated for sharing the details of their program and for sharing powerful comments by participants. For hospitalist medical educators interested in sharing details of effective and sustained innovations, publication of this article emphasizes the Journal of Hospital Medicine's interest in disseminating these important projects.

In summary, the report on the UHMC model challenges all of us in academic hospital medicine to think creatively about how to provide effective, engaging, and exciting learning opportunities beyond the years of medical school and residency training.

Hospitalists, and physicians in general, recognize the need for continuing medical education (CME) to update their knowledge and skills to provide the best possible care for patients. Interactive and personalized learning activities provide the most effective approaches for maintaining or improving physician competency.[1, 2] Despite guidelines that recommend a shift of CME from the traditional large lecture format to case‐based and highly interactive learning techniques,[3] this has been challenging to achieve in practice.

In this issue of the Journal of Hospital Medicine, Sehgal and collaborators at the University of California, San Francisco (UCSF) report innovative and highly appealing CME activity that provides a short, focused experience for the practicing hospitalist seeking to update his or her skills.[4] The UCSF Hospitalist Mini‐College (UHMC) embraced the principles for creation of effective CME by conducting needs assessment from community hospitalists and constructing a program that provides focused, interactive, small‐group, intensive experiences and then evaluating the experience to improve subsequent iterations of the Mini‐College. The UHMC immerses participants in a relatively intense experience that includes close interaction with prominent faculty, hands‐on bedside experiences, practical skills, and attendance at sessions (resident report, morbidity and mortality conferences) that are part of every resident trainee's experience. Participants would be linked to their previous learning activities. As the authors point out, there may be a powerful stimulus to learning when practicing physicians return to the milieu of training environments. This observation deserves further investigation.

The report does not provide evidence that participation in the Mini‐College improved patient outcomes or physician performance in practice; these outcome measures remain elusive and an aspirational goal in medical education research. However, experienced clinician educators have come to recognize and adopt effective interventions that simply make sense in the same fashion that it makes sense to use a parachute when jumping out of an airplane in flight.[5] The UHMC makes sense. The medical education literature is replete with articles describing educational innovations and their 1‐ to 2‐year outcomes, leaving the reader wondering about sustainability. It is reassuring that Sehgal et al. report 5 years of experience with the UHMC, and that the program has consistently had a waiting list of hospitalists who want to participate despite the expense. Although it requires patience on the part of educational innovators, this report helps set a standard for reporting enduring innovation in the education arena.

The article provides a description that is sufficiently detailed for other academic medical centers to replicate the intervention or to effectively adapt the principles of the intervention for the needs of their local hospitalist community. The authors should be congratulated for sharing the details of their program and for sharing powerful comments by participants. For hospitalist medical educators interested in sharing details of effective and sustained innovations, publication of this article emphasizes the Journal of Hospital Medicine's interest in disseminating these important projects.

In summary, the report on the UHMC model challenges all of us in academic hospital medicine to think creatively about how to provide effective, engaging, and exciting learning opportunities beyond the years of medical school and residency training.

At the core of a good physician is mastery of critical communication skills. Good communication establishes rapport and can also heal patients. As communication is an essential ingredient of good physicianship, the recipe starts with a fundamental staplethe physician introduction. The physician introduction is step 2 of Kahn's etiquette‐based medicine checklist to promote good doctoring.[1] Although such rudimentary communication skills are cemented in kindergarten, sadly, more training is needed for doctors. In a recent Journal of Hospital Medicine study, interns failed to introduce themselves in 3 out of 5 inpatient encounters.[2]

Despite waning introductions, increasing importance is being placed on hospitalized patient's knowledge of their treating physician's name and role for patient safety. The Transitions of Care Consensus Policy Statement endorsed by 6 medical societies, including the Society of Hospital Medicine, recommend patients know who their treating physician is while caring for them at every step across the continuum, including hospitalization.[3] The Accreditation Council for Graduate Medical Education requires that patients be informed of who the supervising physician is and understand the roles of any trainees in their care.[4] Last, the death of young Lewis Blackman in South Carolina resulted in state legislation requiring clear identification of physicians and their roles for patients.[5] Given these recommendations, tools to remind physicians to introduce themselves and explain their role to patients are worth consideration. In this issue of the Journal of Hospital Medicine, the effectiveness of 2 interventions using physician photo tools is described.[6, 7]

Even though both studies advance our knowledge on the effectiveness of such interventions, nonrandom variable uptake by physicians represents a major common hurdle. Physician workload, competing priorities, and time pressures prevent physicians from distributing such tools. Consistent adopters of the cards likely already introduce themselves regularly. Interestingly, physicians likely withhold the cards from patients they perceive as unsatisfied, who ironically have the most to gain. System changes, such as increasing handoffs and transient coverage with resident duty hours, can also hamper tool effectiveness through the introduction of more physicians to remember, inherently decreasing the ability of patients to identify their treating physicians.[8]

Patient factors also affect the success of such interventions. Interestingly, patients' baseline ability to identify their physician ranged from 11% to 51% in these studies. Such differences can be readily attributed to previous disparities noted by age, race, gender, and education level in patient recall of their physician.[8] Future work should target interventions for these subgroups, while also accounting for the high prevalence of low health literacy, memory impairment, sleep loss, and poor vision among inpatients, all of which can hamper such interventions.[9, 10]

Although neither intervention improved overall patient satisfaction, patient satisfaction is influenced by a variety of factors unrelated to physician care, such as nursing or the environment. Given the inherent ceiling effect in patient satisfaction metrics, both studies were underpowered to show minor differences. It is also worth noting that complex social interventions depend on their context. Although some patients may enjoy receiving the cards, others may feel that it is not critical to their patient satisfaction. Using a realist evaluation would ask patients what they thought of the cards and why.[11] Like one of the authors, we noted that patients do like the cards, suggesting the problem is not the cards but the metrics of evaluation.[12]

In addition to robust evaluation metrics, future interventions should incorporate patient‐centered approaches to empower patients to ask their doctors about their name and role. With the request coming from patients, doctors are much more likely to comply. Using lessons from marketing and advertising, the hospital is full of artifacts, such as white boards, wristbands, remote controls, and monitors, that can be repurposed to advertise the doctor's name to the patient. Future advances can exploit new mobile technologies and repurpose old ones, such as the hospital television, to remind patients of their care team and other critical information. Regardless of what the future may bring, let's face itintroducing yourself properly to your patients is always good medicine.

At the core of a good physician is mastery of critical communication skills. Good communication establishes rapport and can also heal patients. As communication is an essential ingredient of good physicianship, the recipe starts with a fundamental staplethe physician introduction. The physician introduction is step 2 of Kahn's etiquette‐based medicine checklist to promote good doctoring.[1] Although such rudimentary communication skills are cemented in kindergarten, sadly, more training is needed for doctors. In a recent Journal of Hospital Medicine study, interns failed to introduce themselves in 3 out of 5 inpatient encounters.[2]

Despite waning introductions, increasing importance is being placed on hospitalized patient's knowledge of their treating physician's name and role for patient safety. The Transitions of Care Consensus Policy Statement endorsed by 6 medical societies, including the Society of Hospital Medicine, recommend patients know who their treating physician is while caring for them at every step across the continuum, including hospitalization.[3] The Accreditation Council for Graduate Medical Education requires that patients be informed of who the supervising physician is and understand the roles of any trainees in their care.[4] Last, the death of young Lewis Blackman in South Carolina resulted in state legislation requiring clear identification of physicians and their roles for patients.[5] Given these recommendations, tools to remind physicians to introduce themselves and explain their role to patients are worth consideration. In this issue of the Journal of Hospital Medicine, the effectiveness of 2 interventions using physician photo tools is described.[6, 7]

Even though both studies advance our knowledge on the effectiveness of such interventions, nonrandom variable uptake by physicians represents a major common hurdle. Physician workload, competing priorities, and time pressures prevent physicians from distributing such tools. Consistent adopters of the cards likely already introduce themselves regularly. Interestingly, physicians likely withhold the cards from patients they perceive as unsatisfied, who ironically have the most to gain. System changes, such as increasing handoffs and transient coverage with resident duty hours, can also hamper tool effectiveness through the introduction of more physicians to remember, inherently decreasing the ability of patients to identify their treating physicians.[8]

Patient factors also affect the success of such interventions. Interestingly, patients' baseline ability to identify their physician ranged from 11% to 51% in these studies. Such differences can be readily attributed to previous disparities noted by age, race, gender, and education level in patient recall of their physician.[8] Future work should target interventions for these subgroups, while also accounting for the high prevalence of low health literacy, memory impairment, sleep loss, and poor vision among inpatients, all of which can hamper such interventions.[9, 10]

Although neither intervention improved overall patient satisfaction, patient satisfaction is influenced by a variety of factors unrelated to physician care, such as nursing or the environment. Given the inherent ceiling effect in patient satisfaction metrics, both studies were underpowered to show minor differences. It is also worth noting that complex social interventions depend on their context. Although some patients may enjoy receiving the cards, others may feel that it is not critical to their patient satisfaction. Using a realist evaluation would ask patients what they thought of the cards and why.[11] Like one of the authors, we noted that patients do like the cards, suggesting the problem is not the cards but the metrics of evaluation.[12]

In addition to robust evaluation metrics, future interventions should incorporate patient‐centered approaches to empower patients to ask their doctors about their name and role. With the request coming from patients, doctors are much more likely to comply. Using lessons from marketing and advertising, the hospital is full of artifacts, such as white boards, wristbands, remote controls, and monitors, that can be repurposed to advertise the doctor's name to the patient. Future advances can exploit new mobile technologies and repurpose old ones, such as the hospital television, to remind patients of their care team and other critical information. Regardless of what the future may bring, let's face itintroducing yourself properly to your patients is always good medicine.

At the core of a good physician is mastery of critical communication skills. Good communication establishes rapport and can also heal patients. As communication is an essential ingredient of good physicianship, the recipe starts with a fundamental staplethe physician introduction. The physician introduction is step 2 of Kahn's etiquette‐based medicine checklist to promote good doctoring.[1] Although such rudimentary communication skills are cemented in kindergarten, sadly, more training is needed for doctors. In a recent Journal of Hospital Medicine study, interns failed to introduce themselves in 3 out of 5 inpatient encounters.[2]

Despite waning introductions, increasing importance is being placed on hospitalized patient's knowledge of their treating physician's name and role for patient safety. The Transitions of Care Consensus Policy Statement endorsed by 6 medical societies, including the Society of Hospital Medicine, recommend patients know who their treating physician is while caring for them at every step across the continuum, including hospitalization.[3] The Accreditation Council for Graduate Medical Education requires that patients be informed of who the supervising physician is and understand the roles of any trainees in their care.[4] Last, the death of young Lewis Blackman in South Carolina resulted in state legislation requiring clear identification of physicians and their roles for patients.[5] Given these recommendations, tools to remind physicians to introduce themselves and explain their role to patients are worth consideration. In this issue of the Journal of Hospital Medicine, the effectiveness of 2 interventions using physician photo tools is described.[6, 7]

Even though both studies advance our knowledge on the effectiveness of such interventions, nonrandom variable uptake by physicians represents a major common hurdle. Physician workload, competing priorities, and time pressures prevent physicians from distributing such tools. Consistent adopters of the cards likely already introduce themselves regularly. Interestingly, physicians likely withhold the cards from patients they perceive as unsatisfied, who ironically have the most to gain. System changes, such as increasing handoffs and transient coverage with resident duty hours, can also hamper tool effectiveness through the introduction of more physicians to remember, inherently decreasing the ability of patients to identify their treating physicians.[8]

Patient factors also affect the success of such interventions. Interestingly, patients' baseline ability to identify their physician ranged from 11% to 51% in these studies. Such differences can be readily attributed to previous disparities noted by age, race, gender, and education level in patient recall of their physician.[8] Future work should target interventions for these subgroups, while also accounting for the high prevalence of low health literacy, memory impairment, sleep loss, and poor vision among inpatients, all of which can hamper such interventions.[9, 10]

Although neither intervention improved overall patient satisfaction, patient satisfaction is influenced by a variety of factors unrelated to physician care, such as nursing or the environment. Given the inherent ceiling effect in patient satisfaction metrics, both studies were underpowered to show minor differences. It is also worth noting that complex social interventions depend on their context. Although some patients may enjoy receiving the cards, others may feel that it is not critical to their patient satisfaction. Using a realist evaluation would ask patients what they thought of the cards and why.[11] Like one of the authors, we noted that patients do like the cards, suggesting the problem is not the cards but the metrics of evaluation.[12]

In addition to robust evaluation metrics, future interventions should incorporate patient‐centered approaches to empower patients to ask their doctors about their name and role. With the request coming from patients, doctors are much more likely to comply. Using lessons from marketing and advertising, the hospital is full of artifacts, such as white boards, wristbands, remote controls, and monitors, that can be repurposed to advertise the doctor's name to the patient. Future advances can exploit new mobile technologies and repurpose old ones, such as the hospital television, to remind patients of their care team and other critical information. Regardless of what the future may bring, let's face itintroducing yourself properly to your patients is always good medicine.

2013 WAS A GREAT YEAR FOR JHM

As the field of hospital medicine continues to grow and prosper, so does the Journal of Hospital Medicine (JHM). For JHM, 2013 reflected the field's growth with continued excellence, as manifested in a number of ways.

First, submissions to JHM rose more than 25% over 2012, with the majority of this growth coming in the form of original research, a key indication of vigorous growth in hospital medicine. Growth in submissions was accommodated through a switch to monthly publication frequency, allowing the journal to keep acceptance rates equivalent over time.

Second, peer review time has markedly improved, with average times to first decision falling from more than 35 days in 2011 to fewer than 26 days in 2013. At the same time, the time to papers appearing in Early View fell from more than 3 months to under 2 months, and the time to appearance in print fell to 2 months. Time to decision and time to publication are important measures for the journal, as they represent JHM's service to authors while also ensuring timely publication of articles that may have relevant external context.

Third, the journal continues to garner attention from the press and frequent downloads by readers (Table 1). The most widely downloaded papers of the last 12 months provided evidence‐based guidelines for medication reconciliation and transitions programs, key features of hospital medicine practice. At least as importantly, clinical research articles were also frequently mentioned in the press and downloaded, and many of these important papers were published in the last year.

Fourth, JHM implemented a social media strategy including Twitter and Facebook efforts that have resulted in rapid follower growth; the JHM twitter feed has more than 600 followers and a rapidly improving social media influence score.

Finally, the JHM editors remain deeply thankful to the many outstanding peer reviewers who contribute their time and expertise to the journal. Through their efforts, each article submitted to JHM is improved, whether published or not. Our peer reviewers help the journal, but also play a key role in ensuring the continued growth of the field of hospital medicine. We single out a select few of our most highly regarded reviewers in this editorial (Table 2), and all of our peer reviewers are acknowledged following this editorial.

SO WHAT WILL 2014 BRING?

JHM continues to anticipate growth in submissions and will be working to accommodate need and maintain acceptance rates at a reasonable level. We feel this is a critical strategy for the journal as we seek to increase the level of academic discourse in hospital medicine. The editors will continue to work to ensure that authors receive a fair and expeditious review, one that will produce an article that is improved, whether or not it is accepted in JHM.

We are also pleased to continue to support the Clinical Cases and Conundrums (CCC) series in JHM. The CCC series is a highly respected part of the journal's offerings, and we have sought to improve JHM's ability to solicit and publish outstanding clinical cases by enlisting the help of a group of outstanding national correspondents who will work with the CCC series editor, Brian Harte, to turn fascinating clinical cases into outstanding publications.

JHM will continue to work to make as many articles open access as possible. Even though Society of Hospital Medicine members have free full‐text access to the journal, many other readers do not have direct access to the JHM articles; we will announce articles that are freely available through our Twitter (@JHospMedicine) and Facebook pages.

In addition, JHM will be announcing new criteria for reporting initial experiences with our evaluations of health system innovations. These criteria will help JHM authors and readers understand whether a quality improvement (or value improvement) program was innovative, whether it is implementable, and whether and how it has impact on patient outcomes.

Finally, JHM will be announcing a new series on healthcare value, to begin in the spring of 2014. More details about this series, which will include reviews of key topics in value improvement written by prominent authors, will be forthcoming. We view this as an incredible opportunity for JHM, and one that will confirm hospital medicine's role as a specialty focused on providing the highest quality and highest value care to its patients.

You should be proud of your journal, and we are pleased to have continued to shepherd its growth over the last 2 years. We look forward to your help in charting JHM's course in 2014 and to continuing to shape the future of hospital medicine.

2013 WAS A GREAT YEAR FOR JHM

As the field of hospital medicine continues to grow and prosper, so does the Journal of Hospital Medicine (JHM). For JHM, 2013 reflected the field's growth with continued excellence, as manifested in a number of ways.

First, submissions to JHM rose more than 25% over 2012, with the majority of this growth coming in the form of original research, a key indication of vigorous growth in hospital medicine. Growth in submissions was accommodated through a switch to monthly publication frequency, allowing the journal to keep acceptance rates equivalent over time.

Second, peer review time has markedly improved, with average times to first decision falling from more than 35 days in 2011 to fewer than 26 days in 2013. At the same time, the time to papers appearing in Early View fell from more than 3 months to under 2 months, and the time to appearance in print fell to 2 months. Time to decision and time to publication are important measures for the journal, as they represent JHM's service to authors while also ensuring timely publication of articles that may have relevant external context.

Third, the journal continues to garner attention from the press and frequent downloads by readers (Table 1). The most widely downloaded papers of the last 12 months provided evidence‐based guidelines for medication reconciliation and transitions programs, key features of hospital medicine practice. At least as importantly, clinical research articles were also frequently mentioned in the press and downloaded, and many of these important papers were published in the last year.

Fourth, JHM implemented a social media strategy including Twitter and Facebook efforts that have resulted in rapid follower growth; the JHM twitter feed has more than 600 followers and a rapidly improving social media influence score.

Finally, the JHM editors remain deeply thankful to the many outstanding peer reviewers who contribute their time and expertise to the journal. Through their efforts, each article submitted to JHM is improved, whether published or not. Our peer reviewers help the journal, but also play a key role in ensuring the continued growth of the field of hospital medicine. We single out a select few of our most highly regarded reviewers in this editorial (Table 2), and all of our peer reviewers are acknowledged following this editorial.

SO WHAT WILL 2014 BRING?

JHM continues to anticipate growth in submissions and will be working to accommodate need and maintain acceptance rates at a reasonable level. We feel this is a critical strategy for the journal as we seek to increase the level of academic discourse in hospital medicine. The editors will continue to work to ensure that authors receive a fair and expeditious review, one that will produce an article that is improved, whether or not it is accepted in JHM.

We are also pleased to continue to support the Clinical Cases and Conundrums (CCC) series in JHM. The CCC series is a highly respected part of the journal's offerings, and we have sought to improve JHM's ability to solicit and publish outstanding clinical cases by enlisting the help of a group of outstanding national correspondents who will work with the CCC series editor, Brian Harte, to turn fascinating clinical cases into outstanding publications.

JHM will continue to work to make as many articles open access as possible. Even though Society of Hospital Medicine members have free full‐text access to the journal, many other readers do not have direct access to the JHM articles; we will announce articles that are freely available through our Twitter (@JHospMedicine) and Facebook pages.

In addition, JHM will be announcing new criteria for reporting initial experiences with our evaluations of health system innovations. These criteria will help JHM authors and readers understand whether a quality improvement (or value improvement) program was innovative, whether it is implementable, and whether and how it has impact on patient outcomes.

Finally, JHM will be announcing a new series on healthcare value, to begin in the spring of 2014. More details about this series, which will include reviews of key topics in value improvement written by prominent authors, will be forthcoming. We view this as an incredible opportunity for JHM, and one that will confirm hospital medicine's role as a specialty focused on providing the highest quality and highest value care to its patients.

You should be proud of your journal, and we are pleased to have continued to shepherd its growth over the last 2 years. We look forward to your help in charting JHM's course in 2014 and to continuing to shape the future of hospital medicine.

2013 WAS A GREAT YEAR FOR JHM

As the field of hospital medicine continues to grow and prosper, so does the Journal of Hospital Medicine (JHM). For JHM, 2013 reflected the field's growth with continued excellence, as manifested in a number of ways.

First, submissions to JHM rose more than 25% over 2012, with the majority of this growth coming in the form of original research, a key indication of vigorous growth in hospital medicine. Growth in submissions was accommodated through a switch to monthly publication frequency, allowing the journal to keep acceptance rates equivalent over time.

Second, peer review time has markedly improved, with average times to first decision falling from more than 35 days in 2011 to fewer than 26 days in 2013. At the same time, the time to papers appearing in Early View fell from more than 3 months to under 2 months, and the time to appearance in print fell to 2 months. Time to decision and time to publication are important measures for the journal, as they represent JHM's service to authors while also ensuring timely publication of articles that may have relevant external context.

Third, the journal continues to garner attention from the press and frequent downloads by readers (Table 1). The most widely downloaded papers of the last 12 months provided evidence‐based guidelines for medication reconciliation and transitions programs, key features of hospital medicine practice. At least as importantly, clinical research articles were also frequently mentioned in the press and downloaded, and many of these important papers were published in the last year.

Fourth, JHM implemented a social media strategy including Twitter and Facebook efforts that have resulted in rapid follower growth; the JHM twitter feed has more than 600 followers and a rapidly improving social media influence score.

Finally, the JHM editors remain deeply thankful to the many outstanding peer reviewers who contribute their time and expertise to the journal. Through their efforts, each article submitted to JHM is improved, whether published or not. Our peer reviewers help the journal, but also play a key role in ensuring the continued growth of the field of hospital medicine. We single out a select few of our most highly regarded reviewers in this editorial (Table 2), and all of our peer reviewers are acknowledged following this editorial.

SO WHAT WILL 2014 BRING?

JHM continues to anticipate growth in submissions and will be working to accommodate need and maintain acceptance rates at a reasonable level. We feel this is a critical strategy for the journal as we seek to increase the level of academic discourse in hospital medicine. The editors will continue to work to ensure that authors receive a fair and expeditious review, one that will produce an article that is improved, whether or not it is accepted in JHM.

We are also pleased to continue to support the Clinical Cases and Conundrums (CCC) series in JHM. The CCC series is a highly respected part of the journal's offerings, and we have sought to improve JHM's ability to solicit and publish outstanding clinical cases by enlisting the help of a group of outstanding national correspondents who will work with the CCC series editor, Brian Harte, to turn fascinating clinical cases into outstanding publications.

JHM will continue to work to make as many articles open access as possible. Even though Society of Hospital Medicine members have free full‐text access to the journal, many other readers do not have direct access to the JHM articles; we will announce articles that are freely available through our Twitter (@JHospMedicine) and Facebook pages.

In addition, JHM will be announcing new criteria for reporting initial experiences with our evaluations of health system innovations. These criteria will help JHM authors and readers understand whether a quality improvement (or value improvement) program was innovative, whether it is implementable, and whether and how it has impact on patient outcomes.

Finally, JHM will be announcing a new series on healthcare value, to begin in the spring of 2014. More details about this series, which will include reviews of key topics in value improvement written by prominent authors, will be forthcoming. We view this as an incredible opportunity for JHM, and one that will confirm hospital medicine's role as a specialty focused on providing the highest quality and highest value care to its patients.

You should be proud of your journal, and we are pleased to have continued to shepherd its growth over the last 2 years. We look forward to your help in charting JHM's course in 2014 and to continuing to shape the future of hospital medicine.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.

In 1968, Weed highlighted the importance of medical documentation when he proposed a single format for notes.[1, 2] Since then, sweeping changes in the technology, the purposes, and the requirements of clinical record keeping have encouraged steady growth of a literature devoted to the chart. Specifically, over the past half century, computers, lawsuits, regulations, and the use of documentation as a tool of billing have all contributed to the transformation of hospital records. In addition, mounting pressure to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic possibilities have combined to make medical documentation far more prolific and far less leisurely. All these changes have stimulated a boom in documentation research coinciding, productively, with an era of rapid advances in the conduct of clinical trials and statistical rigor. However, in important respects research into medical documentation today is not asking the right questions, either in the formulation of hypotheses or in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team enterprise; but documentation research has not embraced this development. At the same time, methodologically, the field suffers from a persistent professional bias in the choice of research outcomes, a bias that limits the interpretation of results by neglecting what happens to the patient.

In assessing the chart as a communication device and the effect of changes in documentation, it is increasingly necessary to study direct interpersonal communication as an alternative and partner to writing notes. In particular, 3 recent developments in healthcare emphasize the importance of broadening our concepts of clinical communication. First, the need for discussion in the medical record has become less pressing because of technical improvements in person‐to‐person communication. Second, the electronic health record, by creating discipline‐defined chart views, has helped equalize the stature of different healthcare disciplines but also Balkanized the chart, making direct interdisciplinary communication more necessary. Third, changes in reimbursement are redefining medical goals in such a way that only teams of healthcare providers in close and constant personal communication can achieve them.

Rapid adoption of electronic health records has encouraged researchers studying documentation or information technology to focus on computer formats as defining the range of all possible communication strategies. And certainly there is a broad range of formats: electronic progress notes may be free text or multiple choice, typed or dictated, copy forwarded or composed daily, institutionally templated or self‐templated, furnished with or free from prompts and pop‐ups. However, it is not only, and perhaps not even principally, the electronic record that has changed how clinicians communicate with each other. The technology of discussion over the last 2 decades has become instant, utterly mobile, device independent, and capable of connecting all the patient's caregivers at once to each other and to the medical record in text, picture, and sound. That the same communications upheaval has visited practically every other aspect of our lives diminishes perhaps the visibility of this new virtual team in healthcare but not its importance.

The electronic record certainly plays a role in facilitating communication, through simultaneous chart access and in many other ways, but even more significant is the effect that computerization has had on equalizing the roles of different disciplines and by doing so in fragmenting the medical record. A computerized record expands and reorganizes the chart, changing it from a single authoritative book read by all to an almost limitless array of chart views, each read by some. All viewers (patient, clinician or researcher, administrator, reviewer or coder) can, with equal claim to consulting the chart, categorize, compare, combine, and format data elements from 1 or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and uses but has no owner. Data are entered by protocol and in different guises into many aspects of patient care as components of notes, flow sheets, summaries, pop‐ups, and order sets unique to each of a number of disciplines. As the electronic record equalizes but also separates members of the healthcare team, interdisciplinary personal communication becomes more, not less, important.

Recent and impending reimbursement reform proves also to be a means of democratizing medical care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved over decades from day rates to payments for specific diseases, a system under which profit margins are in theory determined by the interdisciplinary efficiency with which diseases are managed by all care givers and the accuracy with which that management is documented. The next, seemingly inexorable, step in the evolution of reimbursement will result in further democratization of care givers: a single combined disease episode payment will be divided among all those involved in a course of treatment that may span many months and require many disciplines and many types of intervention. Payment reform makes the success of a visiting nurse as important to the net reimbursement of a disease episode as the success of an orthopedic surgeon; for if the visiting nurse does not do well the patient will be readmitted or require more office services. In this sense, payment reform, like the electronic record, tends both to equalize the importance of different healthcare roles and to require their enhanced communication.

As these changes in technology and reimbursement evolve, the study of medical documentation must increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation consumes so many hours and removes caretakers from patients, will no longer serve any demonstrable purpose.[3, 4] It may be that consensus summaries will prove more useful in clarifying one's own thinking and incorporating that of others than will a daily, solo chart soliloquy in free or imported text. It is conceivable that contrasting views will be best presented not as a debate in the progress notes but as a plan mutually agreed upon earlier in the decision‐making process. These are the kind of broader questions that investigators in medical documentation should be pursuing.

Another problem in studies of documentation is a pervasive professional bias in the choice of end points. Studies tend to evaluate documentary practices not by their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing; note quality is judged using a checklist derived from professional surveys.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] End points like these will often make 1 document look better than another in a results section, but it is the relation between communication strategies and healthcare outcomes that determines whether 1 approach or another is of benefit to the patient.

For example, an important current debate is whether free text adds essential nuance to a note or is simply nostalgia, a relic of the 3‐ring binder.[16, 17, 18] This debate can be resolved convincingly only if improvement with the use or abolition of free text is measured in terms of patient outcomes or resource consumption. Again, if it is important to know whether progress notes of a particular length or structure create less handover confusion, then changes in medical error rates is a more persuasive way to evaluate this issue than a change in physician opinion. It may be a good question whether briefer notes will free nurses and doctors to spend more time at the bedside, but along with recording bedside time that study should also measure improvement in reacting to important changes of clinical status. With today's technology, group phone discussions could perhaps successfully replace examining each other's notes, but the measure of success should be improved hospital efficiency or a decline in errors and readmissions.

The questions we ask in our research today create the treatments and policies of tomorrow. Our studies must address communications in a larger sense, must encompass all the settings in which an episode of care occurs, and must focus on patient outcomes and use of resources. The measured end points of an intervention should of course be sensitive to the particular setting where the intervention takes place, or else small and location‐specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion checklists, and clinician adoption or satisfaction in the design of documentation studies.

A great national experiment is underway involving the deployment of information technology, the expansion and empowerment of healthcare teams, and the retargeting of economic incentives. The experimental hypothesis is that technology will increase medical efficiency and will benefit patient well‐being only if these are in fact the purposes, and if teamwork is the principal means, of providing medical care. We should seize this time of change as an opportunity to measure and demonstrably improve the contribution of medical documentation and communication to the efficient and long‐term remission of disease.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

In this issue of the Journal of Hospital Medicine, Hansen and colleagues provide a first, early look at the effectiveness of the BOOST intervention to reduce 30‐day readmissions among hospitalized patients.[1] BOOST[2] is 1 of a number of care transition improvement methodologies that have been applied to the problem of readmissions, each of which has evidence to support its effectiveness in its initial settings[3, 4] but has proven to be difficult to translate to other sites.[5, 6, 7]

BOOST stands in contrast with other, largely research protocol‐derived, programs in that it allows sites to tailor adoption of recommendations to local contexts and is therefore potentially more feasible to implement. Feasibility and practicality has led BOOST to be adopted in large national settings, even if it has had little evidence to support its effectiveness to date.

Given the nonstandardized and ad hoc nature of most multicenter collaboratives generally, and the flexibility of the BOOST model specifically, the BOOST authors are to be commended for undertaking any evaluation at all. Perhaps, not surprisingly, they encountered many of the problems associated with a multicenter studydropout of sites, problematic data, and limited evidence for adoption of the intervention at participating hospitals. Although these represent real‐world experiences of a quality‐improvement program, as a group they pose a number of problems that limit the study's robustness, and generate important caveats that readers should use to temper their interpretation of the authors' findings.

The first caveat relates to the substantial number of sites that either dropped out of BOOST or failed to submit data after enlisting in the collaborative. Although this may be common in quality improvement collaboratives, similar problems would not be permissible in a trial of a new drug or device. Dropout and selected ability to contribute data suggest that the ability to fully adopt BOOST may not be universal, and raises the possibility of bias, because the least successful sites may have had less interest in remaining engaged and submitting data.

The second caveat relates to how readmission rates were assessed. Because sites provided rates of readmissions at the unit level rather than the actual counts of admissions or readmissions, the authors were unable to conduct statistical analyses typically performed for these interventions, such as time series or difference‐in‐difference analyses. More importantly, one cannot discern whether their results are driven by a small absolute but large relative change in the number of readmissions at small sites. That is, large percentage changes of low statistical significance could have misleadingly affected the overall results. Conversely, we cannot identify large sites where a similar relative reduction could be statistically significant and more broadly interpreted as representing the real effectiveness of BOOST efforts.

The third caveat is in regard to the data describing the sites' performance. The effectiveness of BOOST in this analysis varied greatly among sites, with only 1 site showing a strong reduction in readmission rate, and nearly all others showing no statistical improvements. In fact, it appears that their overall results were almost entirely driven by the improvements at that 1 site.

Variable effectiveness of an intervention can be related to variable adoption or contextual factors (such as availability of personnel to implement the program). Although these authors have data on BOOST programmatic adoption, they do not have qualitative data on local barriers and facilitators to BOOST implementation, which at this stage of evaluation would be particularly valuable in understanding the results. Analyzing site‐level effectiveness is of growing relevance to multicenter quality improvement collaboratives,[8, 9] but this evaluation provides little insight into reasons for variable success across institutions.

Finally, their study design does not allow us to understand a number of key questions. How many patients were involved in the intervention? How many patients received all BOOST‐recommended interventions? Which of these interventions seemed most effective in which patients? To what degree did patient severity of illness, cognitive status, social supports, or access to primary care influence readmission risk? Such information would help frame cost‐effective deployment of BOOST or related tools.

In the end, it seems unlikely that this iteration of the BOOST program produced broad reductions in readmission rates. Having said this, the authors provide the necessary start down the road toward a fuller understanding of real‐world efforts to reduce readmissions. Stated alternately, the nuances and flaws of this study provide ample fodder for others working in the field. BOOST is in good stead with other care transition models that have not translated well from their initial research environment to real‐world practices. The question now is: Do any of these interventions actually work in clinical practice settings, and will we ever know? Even more fundamentally, how important and meaningful are these hospital‐based care transition interventions? Where is the engagement with primary care? Where are the primary care outcomes? Does BOOST truly impact outcomes other than readmission?[10]

Doing high‐quality research in the context of a rapidly evolving quality improvement program is hard. Doing it at more than 1 site is harder. BOOST's flexibility is both a great source of strength and a clear challenge to rigorous evaluation. However, when the costs of care transition programs are so high, and the potential consequences of high readmission rates are so great for patients and for hospitals, the need to address these issues with real data and better evidence is paramount. We look forward to the next phase of BOOST and to the growth and refinement of the evidence base for how to improve care coordination and transitions effectively.

In this issue of the Journal of Hospital Medicine, Hansen and colleagues provide a first, early look at the effectiveness of the BOOST intervention to reduce 30‐day readmissions among hospitalized patients.[1] BOOST[2] is 1 of a number of care transition improvement methodologies that have been applied to the problem of readmissions, each of which has evidence to support its effectiveness in its initial settings[3, 4] but has proven to be difficult to translate to other sites.[5, 6, 7]

BOOST stands in contrast with other, largely research protocol‐derived, programs in that it allows sites to tailor adoption of recommendations to local contexts and is therefore potentially more feasible to implement. Feasibility and practicality has led BOOST to be adopted in large national settings, even if it has had little evidence to support its effectiveness to date.

Given the nonstandardized and ad hoc nature of most multicenter collaboratives generally, and the flexibility of the BOOST model specifically, the BOOST authors are to be commended for undertaking any evaluation at all. Perhaps, not surprisingly, they encountered many of the problems associated with a multicenter studydropout of sites, problematic data, and limited evidence for adoption of the intervention at participating hospitals. Although these represent real‐world experiences of a quality‐improvement program, as a group they pose a number of problems that limit the study's robustness, and generate important caveats that readers should use to temper their interpretation of the authors' findings.

The first caveat relates to the substantial number of sites that either dropped out of BOOST or failed to submit data after enlisting in the collaborative. Although this may be common in quality improvement collaboratives, similar problems would not be permissible in a trial of a new drug or device. Dropout and selected ability to contribute data suggest that the ability to fully adopt BOOST may not be universal, and raises the possibility of bias, because the least successful sites may have had less interest in remaining engaged and submitting data.

The second caveat relates to how readmission rates were assessed. Because sites provided rates of readmissions at the unit level rather than the actual counts of admissions or readmissions, the authors were unable to conduct statistical analyses typically performed for these interventions, such as time series or difference‐in‐difference analyses. More importantly, one cannot discern whether their results are driven by a small absolute but large relative change in the number of readmissions at small sites. That is, large percentage changes of low statistical significance could have misleadingly affected the overall results. Conversely, we cannot identify large sites where a similar relative reduction could be statistically significant and more broadly interpreted as representing the real effectiveness of BOOST efforts.

The third caveat is in regard to the data describing the sites' performance. The effectiveness of BOOST in this analysis varied greatly among sites, with only 1 site showing a strong reduction in readmission rate, and nearly all others showing no statistical improvements. In fact, it appears that their overall results were almost entirely driven by the improvements at that 1 site.

Variable effectiveness of an intervention can be related to variable adoption or contextual factors (such as availability of personnel to implement the program). Although these authors have data on BOOST programmatic adoption, they do not have qualitative data on local barriers and facilitators to BOOST implementation, which at this stage of evaluation would be particularly valuable in understanding the results. Analyzing site‐level effectiveness is of growing relevance to multicenter quality improvement collaboratives,[8, 9] but this evaluation provides little insight into reasons for variable success across institutions.

Finally, their study design does not allow us to understand a number of key questions. How many patients were involved in the intervention? How many patients received all BOOST‐recommended interventions? Which of these interventions seemed most effective in which patients? To what degree did patient severity of illness, cognitive status, social supports, or access to primary care influence readmission risk? Such information would help frame cost‐effective deployment of BOOST or related tools.

In the end, it seems unlikely that this iteration of the BOOST program produced broad reductions in readmission rates. Having said this, the authors provide the necessary start down the road toward a fuller understanding of real‐world efforts to reduce readmissions. Stated alternately, the nuances and flaws of this study provide ample fodder for others working in the field. BOOST is in good stead with other care transition models that have not translated well from their initial research environment to real‐world practices. The question now is: Do any of these interventions actually work in clinical practice settings, and will we ever know? Even more fundamentally, how important and meaningful are these hospital‐based care transition interventions? Where is the engagement with primary care? Where are the primary care outcomes? Does BOOST truly impact outcomes other than readmission?[10]

Doing high‐quality research in the context of a rapidly evolving quality improvement program is hard. Doing it at more than 1 site is harder. BOOST's flexibility is both a great source of strength and a clear challenge to rigorous evaluation. However, when the costs of care transition programs are so high, and the potential consequences of high readmission rates are so great for patients and for hospitals, the need to address these issues with real data and better evidence is paramount. We look forward to the next phase of BOOST and to the growth and refinement of the evidence base for how to improve care coordination and transitions effectively.

In this issue of the Journal of Hospital Medicine, Hansen and colleagues provide a first, early look at the effectiveness of the BOOST intervention to reduce 30‐day readmissions among hospitalized patients.[1] BOOST[2] is 1 of a number of care transition improvement methodologies that have been applied to the problem of readmissions, each of which has evidence to support its effectiveness in its initial settings[3, 4] but has proven to be difficult to translate to other sites.[5, 6, 7]

BOOST stands in contrast with other, largely research protocol‐derived, programs in that it allows sites to tailor adoption of recommendations to local contexts and is therefore potentially more feasible to implement. Feasibility and practicality has led BOOST to be adopted in large national settings, even if it has had little evidence to support its effectiveness to date.

Given the nonstandardized and ad hoc nature of most multicenter collaboratives generally, and the flexibility of the BOOST model specifically, the BOOST authors are to be commended for undertaking any evaluation at all. Perhaps, not surprisingly, they encountered many of the problems associated with a multicenter studydropout of sites, problematic data, and limited evidence for adoption of the intervention at participating hospitals. Although these represent real‐world experiences of a quality‐improvement program, as a group they pose a number of problems that limit the study's robustness, and generate important caveats that readers should use to temper their interpretation of the authors' findings.

The first caveat relates to the substantial number of sites that either dropped out of BOOST or failed to submit data after enlisting in the collaborative. Although this may be common in quality improvement collaboratives, similar problems would not be permissible in a trial of a new drug or device. Dropout and selected ability to contribute data suggest that the ability to fully adopt BOOST may not be universal, and raises the possibility of bias, because the least successful sites may have had less interest in remaining engaged and submitting data.

The second caveat relates to how readmission rates were assessed. Because sites provided rates of readmissions at the unit level rather than the actual counts of admissions or readmissions, the authors were unable to conduct statistical analyses typically performed for these interventions, such as time series or difference‐in‐difference analyses. More importantly, one cannot discern whether their results are driven by a small absolute but large relative change in the number of readmissions at small sites. That is, large percentage changes of low statistical significance could have misleadingly affected the overall results. Conversely, we cannot identify large sites where a similar relative reduction could be statistically significant and more broadly interpreted as representing the real effectiveness of BOOST efforts.

The third caveat is in regard to the data describing the sites' performance. The effectiveness of BOOST in this analysis varied greatly among sites, with only 1 site showing a strong reduction in readmission rate, and nearly all others showing no statistical improvements. In fact, it appears that their overall results were almost entirely driven by the improvements at that 1 site.

Variable effectiveness of an intervention can be related to variable adoption or contextual factors (such as availability of personnel to implement the program). Although these authors have data on BOOST programmatic adoption, they do not have qualitative data on local barriers and facilitators to BOOST implementation, which at this stage of evaluation would be particularly valuable in understanding the results. Analyzing site‐level effectiveness is of growing relevance to multicenter quality improvement collaboratives,[8, 9] but this evaluation provides little insight into reasons for variable success across institutions.

Finally, their study design does not allow us to understand a number of key questions. How many patients were involved in the intervention? How many patients received all BOOST‐recommended interventions? Which of these interventions seemed most effective in which patients? To what degree did patient severity of illness, cognitive status, social supports, or access to primary care influence readmission risk? Such information would help frame cost‐effective deployment of BOOST or related tools.

In the end, it seems unlikely that this iteration of the BOOST program produced broad reductions in readmission rates. Having said this, the authors provide the necessary start down the road toward a fuller understanding of real‐world efforts to reduce readmissions. Stated alternately, the nuances and flaws of this study provide ample fodder for others working in the field. BOOST is in good stead with other care transition models that have not translated well from their initial research environment to real‐world practices. The question now is: Do any of these interventions actually work in clinical practice settings, and will we ever know? Even more fundamentally, how important and meaningful are these hospital‐based care transition interventions? Where is the engagement with primary care? Where are the primary care outcomes? Does BOOST truly impact outcomes other than readmission?[10]

Doing high‐quality research in the context of a rapidly evolving quality improvement program is hard. Doing it at more than 1 site is harder. BOOST's flexibility is both a great source of strength and a clear challenge to rigorous evaluation. However, when the costs of care transition programs are so high, and the potential consequences of high readmission rates are so great for patients and for hospitals, the need to address these issues with real data and better evidence is paramount. We look forward to the next phase of BOOST and to the growth and refinement of the evidence base for how to improve care coordination and transitions effectively.

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.