Expert Commentary

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Nelson

By now, I’m sure you’re knowledgeable about things like healthcare exchanges and other parts of the Accountable Care Act, the increasing number of metrics within hospital value-based purchasing, the physician value-based payment modifier, the physician quality reporting system (PQRS), how to use your hospital’s new EHR efficiently, the new “two-midnight rule” to determine inpatient vs. observation status, and so on.

You’re to be commended if you’re staying on top of all these things and have effective plans in place to ensure good performance on each. And if you haven’t already, you should add at least one more important issue to this list—the transition to ICD-10 coding on Oct. 1, 2014.

An Overview

ICD stands for International Classification of Diseases, and the U.S. has been using the 9th revision (ICD-9) since 1978. ICD-9 is now significantly out of step with current medical knowledge and has run out of codes in some disease sections (“chapters”). This might mean, for example, that new codes for heart diseases would be assigned to the chapter for eye disease, because the former is full.

ICD-10 provides a way to fix these problems and, through more specific coding of diseases, should be able to yield more useful “big data” to measure things like safety and efficacy of care and more accurately identify diagnosis trends and epidemics. And, in theory, it could reduce the number of rejected billing claims, though I’m waiting to see if that happens. I worry that even after fixing all the initial bugs related to the ICD-10 transition, we will see more claim rejections than we experience today.

ICD codes can be thought of as diagnosis codes. CPT codes (Current Procedural Terminology) are an entirely separate set of codes that we use to report the work we do for the purposes of billing. We need to be familiar with both, but it is the ICD codes that are changing.

ICD-10 Basics and Trivia

The World Health Organization issued the ICD-10 in 1994, and it is already in use in many countries. Like some other countries, the U.S. made modifications to the WHO’s original code set, so we refer to ICD-10-CM (Clinical Modification), which contains diagnosis codes. The National Center for Health Statistics, a department of the CDC, is responsible for these modifications.

The WHO version of ICD-10 doesn’t have any procedure codes, so CMS developed ICD-10-PCS (Procedure Coding System) to report procedures, such as surgeries, done in U.S. hospitals. Most hospitalists won’t use these procedure codes often.

Dr. Nelson

Table 1 (left) compares ICD-10-CM to ICD-9-CM. Most of the additional codes in the new version simply add information regarding whether the diagnosis is on the left or right of the body, acute or chronic, or an initial or subsequent visit for the condition. But the standard structure for each code had to be modified significantly to capture this additional information. Some highlights of the seven-character code structure are:

• Characters 1–3: category; first digit always a letter, second digit always a number, all other digits can be either; not case sensitive;
• Characters 4–6: etiology, anatomic site, severity, or other clinical detail; for example, 1=right, 2=left, 3-bilateral, and 0 or 9=unspecified; and
• Character 7: extension (i.e., A=initial encounter, D=subsequent encounter, S=sequelae).
• A placeholder “x” is used as needed to fill in empty characters to ensure that the seventh character stays in the seventh position. For example, T79.1xxA equates to “fat embolism, initial encounter.” (Note that the “dummy” characters could create problems for some IT systems.)

An example of more information contained in additional characters:

• S52=fracture of forearm.
• S52.5=fracture of lower end of radius.
• S52.52=torus fracture of lower end of radius.
• S52.521=torus fracture of lower end of right radius.
• S52.521A=torus fracture of lower end of right radius, initial encounter for closed fracture.

Compared to its predecessor, ICD-10 expands use of combination codes. These are single codes that can be used to classify either two diagnoses, a diagnosis with an associated secondary process, or a diagnosis with an associated complication. For example, rather than reporting acute cor pulmonale and septic pulmonary embolism separately, ICD-10 allows use of the code I26.01: septic pulmonary embolism with acute cor pulmonale.

Resources

In addition to resources on the SHM website, both the American Medical Association (www.ama-assn.org, search “ICD-10”) and the Centers for Medicare and Medicaid Services (www.cms.gov/icd10) have very informative microsites offering detailed ICD-10 information. Much of the information in this column, including the examples above, comes from those sites.

What to Expect

Your hospital and your employer are probably already working in earnest to prepare for the change. In some cases, hospitalists are actively involved in these preparations, but in most cases they will simply wait for an organization to notify them that they should begin training to understand the new coding system. Experts say that most physicians will need two to four hours of training on ICD-10, but because we use a universe of diagnosis codes that is much larger than many specialties, I wonder if hospitalists may need additional training.

Like nearly all the programs I listed at the beginning, the transition to ICD-10 has me concerned. Managing it poorly could mean significant loss in hospital and physician professional fee revenue, as well as lots of tedious and time-consuming work. So, doing it right is important. But, it is also important to do well on all the programs I listed at the beginning of this column, and many others, and there is a limit to just how much we can do effectively as individuals.

Collectively, these programs risk taking too much time and too many brain cells away from keeping up with clinical medicine. So, I wonder if, for many of us, ICD-10 will serve as a tipping point that results in physicians hiring professional coders to choose our diagnosis codes and CPT codes rather than doing it ourselves.

As with EHRs, ICD-10 is said to have many benefits. But the introduction of EHRs in many hospitals had the unintended effect of significantly reducing the number of doctors who were willing to serve as admitting and attending physicians; instead, many chose to refer to hospitalists. In a similar way, ICD-10 might lead many organizations to relieve physicians of the responsibility of looking up and entering codes for each patient, leaving them with more time and energy to be clinicians. We’ll have to wait and see.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.¹ However, the American Cancer Society² and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.

In a recent study, Webb and colleagues³ used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?

What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.

Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.

Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)

Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.

Moreover, this report provides no information on ­treatment ­received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.

How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.

Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.¹ However, the American Cancer Society² and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.

In a recent study, Webb and colleagues³ used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?

What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.

Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.

Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)

Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.

Moreover, this report provides no information on ­treatment ­received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.

How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.

Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.¹ However, the American Cancer Society² and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.

In a recent study, Webb and colleagues³ used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?

What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.

Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.

Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)

Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.

Moreover, this report provides no information on ­treatment ­received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.

How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Every morning before I leave for work, I kiss my three children goodbye and tell them, “I love you. Make good choices today.”

This has become my mantra—so much so that, on her way out the door to join her friends at the movies recently, my daughter turned to me and said, “I know, Dad. I know. I’ll make good decisions tonight.”

And what decision is more important than where to deliver your child and who to have in attendance at the birth?

It is said that the passage from the uterus to the outside world that each one of us was forced to negotiate at birth is the most treacherous journey we will ever undertake. Any unnecessary delay or complication can have profound, lifelong consequences.

There is no question that the past few centuries have seen a significant “medicalization” of childbirth, including the relocation of deliveries from the community to a hospital setting, the introduction of male obstetricians, the unfortunate marginalization of midwives and support personnel (doulas), the development of uterotonic drugs, and the evolution of operative vaginal (forceps, vacuum) and cesarean deliveries.

Many of the practices initially introduced by obstetric care providers (including multiple vaginal examinations in labor, induction of labor for a large baby, and active management of labor protocols) have since been shown to be unhelpful in improving pregnancy outcomes, and some practices (such as episiotomy) have even been shown to be harmful.

Related article: Difficult fetal extraction at cesarean delivery: What should you do? Robert L. Barbieri, MD (Editorial, January 2012)

In the midst of this confusion, the one voice that has been lost is that of the patient herself.

Whose birth is it anyway?
The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American College of Nurse-Midwives (ACNM) all agree that patient autonomy is paramount, and that the final decision of where to deliver and who to have in attendance should be made by the patient herself, ideally in conjunction with her family and her obstetric care provider.^1–3 But an informed decision is only as good as the available data. Regrettably, the literature on how planned home birth compares with hospital delivery in terms of pregnancy outcomes in the United States are sparse.

Related article: Lay midwives the the ObGyn: Is collaboration risky? Lucia DiVenere, MA (May 2012)

How safe is home birth in the United States?
Cheng and colleagues attempt to answer this question by reviewing newborn and maternal outcomes among planned home births versus hospital deliveries in a contemporary low-risk birth cohort. Their retrospective study included low-risk women at term with a singleton vertex live birth in 2008 in 27 of the 50 states using information from the Vital Statistics Natality Data provided by the Centers for Disease Control and Prevention.

Of these 2,081,753 women, 0.58% (n = 12,039) had planned home births, and the remainder delivered in a hospital setting. Women who had an “accidental” (unintended) home birth or who delivered in a freestanding birthing center were excluded. The primary outcome was the risk of a 5-minute Apgar score less than 4. Secondary outcomes included the risk of a 5-minute Apgar score less than 7, assisted ventilation for more than 6 hours, neonatal seizures, admission to the NICU, and a series of maternal outcome measures.

Besides the outcomes listed previously (top of page 24), women with a planned home birth had fewer obstetric interventions, including operative vaginal delivery and labor induction or augmentation. They also were less likely to be given antibiotics during labor (although the authors did not distinguish between antibiotics administered for prophylaxis against group B strep or surgical-site infection versus antibiotics to treat infections such as urinary tract infections or chorioamnionitis).

Of special interest is the fact that neither a prior vaginal delivery (multiparity) nor the absence of a prior cesarean delivery was protective against these adverse events.

The women at highest risk of an adverse event were those who delivered at home under the supervision of “other midwives.” Although these providers were not well defined, this term typically refers to community-based lay midwives whose only “training” consists of an unofficial apprenticeship of variable length. Despite the absence of formal training, the lack of certification and standardization of care, and the existence of legislation in many states banning their activity, such lay midwives continue to encourage and support home birth for both low- and high-risk women in the United States.

Related article: Update on Obstetrics John T. Repke, MD, and Jaimey M. Pauli, MD (January 2012)

Limitations of the study design
Although this dataset contains more than 2 million births, it includes only low-risk women at term and, therefore, is underpowered to measure outcomes such as fetal or neonatal death or birth injuries.

No data were presented on a number of important variables and outcome measures, such as the rate of or indications for cesarean delivery, the mode and frequency of intrapartum fetal monitoring, birth weight, intrapartum complications (uterine rupture, postpartum hemorrhage), blood transfusions, and infectious morbidity. The study also lacks long-term follow-up data on the infants.

That said, the study was well designed and very well written, and many of the limitations listed above are inherent in all retrospective cohort studies.

Putting these findings in context
These data are not novel, but they are remarkably consistent with other publications that have explored pregnancy outcomes in planned home birth versus hospital delivery from the Netherlands, the United Kingdom, Australia, and the United States, all of which show a higher rate of neonatal complications with planned home birth [see Reference 4 for review].⁴

Moreover, it is likely that the data in the current report significantly underestimate the risks of planned home birth for two reasons:

• Attempted home births that ended in transfer and, ultimately, delivery in a hospital setting (presumably for some unforeseen event such as excessive hemorrhage or uterine rupture or cord prolapse or nonreassuring fetal testing) were classified as hospital births.
• Apgar scores at 5 minutes are assigned by the attending care provider, and there is no way to independently verify their accuracy. Because of their limited training and/or concern about efforts to limit the scope of their practice, “other midwives” may be inclined to assign more favorable Apgar scores.

Who is choosing to deliver at home?
The proportion of US women who delivered outside the hospital setting increased by 29% between 2004 and 2009,⁵ although home births still constitute a minority of low-risk births (0.58% in the current study).

Related Article: Why are well-educated women more likely to choose home birth? Errol R. Norwitz, MD, PhD (Audiocast, November 2013)

One of the more interesting questions raised by this publication is the issue of who is choosing to deliver at home. In this cohort, women who planned home birth were more likely to be older, married, multiparous, white, and well educated. These aren’t exactly the women you would expect to gamble with the lives of their unborn offspring. So why are they choosing to deliver at home?

It could be that they are not well informed about the risks. Alternatively, they may have concluded that, although the relative risk of an adverse event is significantly higher with home birth, the absolute risk is low and acceptable to them. Or it could be that they are frustrated by the lack of autonomy afforded to them in the decisions surrounding antenatal care and the birthing process.

In recent years, more women are asking for minimally invasive births that are physically, emotionally, and socially supported. As hospital-based obstetric care providers, we do not always respect or meet these expectations. We can and should do better.

Women should not have to choose between a good birth experience and medical safety, between social support and hospital resources, between a sense of autonomy and access to life-saving interventions. Although every effort should be taken to make the birthing experience a positive one for the mother and her family as a whole, it should not be done at the expense of safety. I have yet to hear an asphyxiated and brain-damaged child thank his mother’s obstetric care provider for allowing a wonderful birth experience.

What this evidence means for practice
Even in countries where home births are integrated fully into the medical care system and attended by trained and certified nurse-midwives, they are associated with increased risks, including a twofold to threefold increase in the odds of neonatal death.4 In the US, where no such integration exists, home births are dangerous.

Maternity care has come a long way since the 17th Century, when a woman had a 1 in 6 chance of dying in childbirth and only one of every five children lived to enjoy a first birthday. It is appropriate in this era of Obamacare and cost containment that we explore alternative methods. The option of a safe home delivery may well be part of the solution, as it is for many European countries--but until we can be assured that such an approach is safe for both mothers and infants, let's keep home delivery where it belongs...for pizza!

--Errol R. Norwitz, MD, PHD

We want to hear from you! Tell us what you think.

Every morning before I leave for work, I kiss my three children goodbye and tell them, “I love you. Make good choices today.”

This has become my mantra—so much so that, on her way out the door to join her friends at the movies recently, my daughter turned to me and said, “I know, Dad. I know. I’ll make good decisions tonight.”

And what decision is more important than where to deliver your child and who to have in attendance at the birth?

It is said that the passage from the uterus to the outside world that each one of us was forced to negotiate at birth is the most treacherous journey we will ever undertake. Any unnecessary delay or complication can have profound, lifelong consequences.

There is no question that the past few centuries have seen a significant “medicalization” of childbirth, including the relocation of deliveries from the community to a hospital setting, the introduction of male obstetricians, the unfortunate marginalization of midwives and support personnel (doulas), the development of uterotonic drugs, and the evolution of operative vaginal (forceps, vacuum) and cesarean deliveries.

Many of the practices initially introduced by obstetric care providers (including multiple vaginal examinations in labor, induction of labor for a large baby, and active management of labor protocols) have since been shown to be unhelpful in improving pregnancy outcomes, and some practices (such as episiotomy) have even been shown to be harmful.

Related article: Difficult fetal extraction at cesarean delivery: What should you do? Robert L. Barbieri, MD (Editorial, January 2012)

In the midst of this confusion, the one voice that has been lost is that of the patient herself.

Whose birth is it anyway?
The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American College of Nurse-Midwives (ACNM) all agree that patient autonomy is paramount, and that the final decision of where to deliver and who to have in attendance should be made by the patient herself, ideally in conjunction with her family and her obstetric care provider.^1–3 But an informed decision is only as good as the available data. Regrettably, the literature on how planned home birth compares with hospital delivery in terms of pregnancy outcomes in the United States are sparse.

Related article: Lay midwives the the ObGyn: Is collaboration risky? Lucia DiVenere, MA (May 2012)

How safe is home birth in the United States?
Cheng and colleagues attempt to answer this question by reviewing newborn and maternal outcomes among planned home births versus hospital deliveries in a contemporary low-risk birth cohort. Their retrospective study included low-risk women at term with a singleton vertex live birth in 2008 in 27 of the 50 states using information from the Vital Statistics Natality Data provided by the Centers for Disease Control and Prevention.

Of these 2,081,753 women, 0.58% (n = 12,039) had planned home births, and the remainder delivered in a hospital setting. Women who had an “accidental” (unintended) home birth or who delivered in a freestanding birthing center were excluded. The primary outcome was the risk of a 5-minute Apgar score less than 4. Secondary outcomes included the risk of a 5-minute Apgar score less than 7, assisted ventilation for more than 6 hours, neonatal seizures, admission to the NICU, and a series of maternal outcome measures.

Besides the outcomes listed previously (top of page 24), women with a planned home birth had fewer obstetric interventions, including operative vaginal delivery and labor induction or augmentation. They also were less likely to be given antibiotics during labor (although the authors did not distinguish between antibiotics administered for prophylaxis against group B strep or surgical-site infection versus antibiotics to treat infections such as urinary tract infections or chorioamnionitis).

Of special interest is the fact that neither a prior vaginal delivery (multiparity) nor the absence of a prior cesarean delivery was protective against these adverse events.

The women at highest risk of an adverse event were those who delivered at home under the supervision of “other midwives.” Although these providers were not well defined, this term typically refers to community-based lay midwives whose only “training” consists of an unofficial apprenticeship of variable length. Despite the absence of formal training, the lack of certification and standardization of care, and the existence of legislation in many states banning their activity, such lay midwives continue to encourage and support home birth for both low- and high-risk women in the United States.

Related article: Update on Obstetrics John T. Repke, MD, and Jaimey M. Pauli, MD (January 2012)

Limitations of the study design
Although this dataset contains more than 2 million births, it includes only low-risk women at term and, therefore, is underpowered to measure outcomes such as fetal or neonatal death or birth injuries.

No data were presented on a number of important variables and outcome measures, such as the rate of or indications for cesarean delivery, the mode and frequency of intrapartum fetal monitoring, birth weight, intrapartum complications (uterine rupture, postpartum hemorrhage), blood transfusions, and infectious morbidity. The study also lacks long-term follow-up data on the infants.

That said, the study was well designed and very well written, and many of the limitations listed above are inherent in all retrospective cohort studies.

Putting these findings in context
These data are not novel, but they are remarkably consistent with other publications that have explored pregnancy outcomes in planned home birth versus hospital delivery from the Netherlands, the United Kingdom, Australia, and the United States, all of which show a higher rate of neonatal complications with planned home birth [see Reference 4 for review].⁴

Moreover, it is likely that the data in the current report significantly underestimate the risks of planned home birth for two reasons:

• Attempted home births that ended in transfer and, ultimately, delivery in a hospital setting (presumably for some unforeseen event such as excessive hemorrhage or uterine rupture or cord prolapse or nonreassuring fetal testing) were classified as hospital births.
• Apgar scores at 5 minutes are assigned by the attending care provider, and there is no way to independently verify their accuracy. Because of their limited training and/or concern about efforts to limit the scope of their practice, “other midwives” may be inclined to assign more favorable Apgar scores.

Who is choosing to deliver at home?
The proportion of US women who delivered outside the hospital setting increased by 29% between 2004 and 2009,⁵ although home births still constitute a minority of low-risk births (0.58% in the current study).

Related Article: Why are well-educated women more likely to choose home birth? Errol R. Norwitz, MD, PhD (Audiocast, November 2013)

One of the more interesting questions raised by this publication is the issue of who is choosing to deliver at home. In this cohort, women who planned home birth were more likely to be older, married, multiparous, white, and well educated. These aren’t exactly the women you would expect to gamble with the lives of their unborn offspring. So why are they choosing to deliver at home?

It could be that they are not well informed about the risks. Alternatively, they may have concluded that, although the relative risk of an adverse event is significantly higher with home birth, the absolute risk is low and acceptable to them. Or it could be that they are frustrated by the lack of autonomy afforded to them in the decisions surrounding antenatal care and the birthing process.

In recent years, more women are asking for minimally invasive births that are physically, emotionally, and socially supported. As hospital-based obstetric care providers, we do not always respect or meet these expectations. We can and should do better.

Women should not have to choose between a good birth experience and medical safety, between social support and hospital resources, between a sense of autonomy and access to life-saving interventions. Although every effort should be taken to make the birthing experience a positive one for the mother and her family as a whole, it should not be done at the expense of safety. I have yet to hear an asphyxiated and brain-damaged child thank his mother’s obstetric care provider for allowing a wonderful birth experience.

What this evidence means for practice
Even in countries where home births are integrated fully into the medical care system and attended by trained and certified nurse-midwives, they are associated with increased risks, including a twofold to threefold increase in the odds of neonatal death.4 In the US, where no such integration exists, home births are dangerous.

Maternity care has come a long way since the 17th Century, when a woman had a 1 in 6 chance of dying in childbirth and only one of every five children lived to enjoy a first birthday. It is appropriate in this era of Obamacare and cost containment that we explore alternative methods. The option of a safe home delivery may well be part of the solution, as it is for many European countries--but until we can be assured that such an approach is safe for both mothers and infants, let's keep home delivery where it belongs...for pizza!

--Errol R. Norwitz, MD, PHD

We want to hear from you! Tell us what you think.

Every morning before I leave for work, I kiss my three children goodbye and tell them, “I love you. Make good choices today.”

This has become my mantra—so much so that, on her way out the door to join her friends at the movies recently, my daughter turned to me and said, “I know, Dad. I know. I’ll make good decisions tonight.”

And what decision is more important than where to deliver your child and who to have in attendance at the birth?

It is said that the passage from the uterus to the outside world that each one of us was forced to negotiate at birth is the most treacherous journey we will ever undertake. Any unnecessary delay or complication can have profound, lifelong consequences.

There is no question that the past few centuries have seen a significant “medicalization” of childbirth, including the relocation of deliveries from the community to a hospital setting, the introduction of male obstetricians, the unfortunate marginalization of midwives and support personnel (doulas), the development of uterotonic drugs, and the evolution of operative vaginal (forceps, vacuum) and cesarean deliveries.

Many of the practices initially introduced by obstetric care providers (including multiple vaginal examinations in labor, induction of labor for a large baby, and active management of labor protocols) have since been shown to be unhelpful in improving pregnancy outcomes, and some practices (such as episiotomy) have even been shown to be harmful.

Related article: Difficult fetal extraction at cesarean delivery: What should you do? Robert L. Barbieri, MD (Editorial, January 2012)

In the midst of this confusion, the one voice that has been lost is that of the patient herself.

Whose birth is it anyway?
The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American College of Nurse-Midwives (ACNM) all agree that patient autonomy is paramount, and that the final decision of where to deliver and who to have in attendance should be made by the patient herself, ideally in conjunction with her family and her obstetric care provider.^1–3 But an informed decision is only as good as the available data. Regrettably, the literature on how planned home birth compares with hospital delivery in terms of pregnancy outcomes in the United States are sparse.

Related article: Lay midwives the the ObGyn: Is collaboration risky? Lucia DiVenere, MA (May 2012)

How safe is home birth in the United States?
Cheng and colleagues attempt to answer this question by reviewing newborn and maternal outcomes among planned home births versus hospital deliveries in a contemporary low-risk birth cohort. Their retrospective study included low-risk women at term with a singleton vertex live birth in 2008 in 27 of the 50 states using information from the Vital Statistics Natality Data provided by the Centers for Disease Control and Prevention.

Of these 2,081,753 women, 0.58% (n = 12,039) had planned home births, and the remainder delivered in a hospital setting. Women who had an “accidental” (unintended) home birth or who delivered in a freestanding birthing center were excluded. The primary outcome was the risk of a 5-minute Apgar score less than 4. Secondary outcomes included the risk of a 5-minute Apgar score less than 7, assisted ventilation for more than 6 hours, neonatal seizures, admission to the NICU, and a series of maternal outcome measures.

Besides the outcomes listed previously (top of page 24), women with a planned home birth had fewer obstetric interventions, including operative vaginal delivery and labor induction or augmentation. They also were less likely to be given antibiotics during labor (although the authors did not distinguish between antibiotics administered for prophylaxis against group B strep or surgical-site infection versus antibiotics to treat infections such as urinary tract infections or chorioamnionitis).

Of special interest is the fact that neither a prior vaginal delivery (multiparity) nor the absence of a prior cesarean delivery was protective against these adverse events.

The women at highest risk of an adverse event were those who delivered at home under the supervision of “other midwives.” Although these providers were not well defined, this term typically refers to community-based lay midwives whose only “training” consists of an unofficial apprenticeship of variable length. Despite the absence of formal training, the lack of certification and standardization of care, and the existence of legislation in many states banning their activity, such lay midwives continue to encourage and support home birth for both low- and high-risk women in the United States.

Related article: Update on Obstetrics John T. Repke, MD, and Jaimey M. Pauli, MD (January 2012)

Limitations of the study design
Although this dataset contains more than 2 million births, it includes only low-risk women at term and, therefore, is underpowered to measure outcomes such as fetal or neonatal death or birth injuries.

No data were presented on a number of important variables and outcome measures, such as the rate of or indications for cesarean delivery, the mode and frequency of intrapartum fetal monitoring, birth weight, intrapartum complications (uterine rupture, postpartum hemorrhage), blood transfusions, and infectious morbidity. The study also lacks long-term follow-up data on the infants.

That said, the study was well designed and very well written, and many of the limitations listed above are inherent in all retrospective cohort studies.

Putting these findings in context
These data are not novel, but they are remarkably consistent with other publications that have explored pregnancy outcomes in planned home birth versus hospital delivery from the Netherlands, the United Kingdom, Australia, and the United States, all of which show a higher rate of neonatal complications with planned home birth [see Reference 4 for review].⁴

Moreover, it is likely that the data in the current report significantly underestimate the risks of planned home birth for two reasons:

• Attempted home births that ended in transfer and, ultimately, delivery in a hospital setting (presumably for some unforeseen event such as excessive hemorrhage or uterine rupture or cord prolapse or nonreassuring fetal testing) were classified as hospital births.
• Apgar scores at 5 minutes are assigned by the attending care provider, and there is no way to independently verify their accuracy. Because of their limited training and/or concern about efforts to limit the scope of their practice, “other midwives” may be inclined to assign more favorable Apgar scores.

Who is choosing to deliver at home?
The proportion of US women who delivered outside the hospital setting increased by 29% between 2004 and 2009,⁵ although home births still constitute a minority of low-risk births (0.58% in the current study).

Related Article: Why are well-educated women more likely to choose home birth? Errol R. Norwitz, MD, PhD (Audiocast, November 2013)

One of the more interesting questions raised by this publication is the issue of who is choosing to deliver at home. In this cohort, women who planned home birth were more likely to be older, married, multiparous, white, and well educated. These aren’t exactly the women you would expect to gamble with the lives of their unborn offspring. So why are they choosing to deliver at home?

It could be that they are not well informed about the risks. Alternatively, they may have concluded that, although the relative risk of an adverse event is significantly higher with home birth, the absolute risk is low and acceptable to them. Or it could be that they are frustrated by the lack of autonomy afforded to them in the decisions surrounding antenatal care and the birthing process.

In recent years, more women are asking for minimally invasive births that are physically, emotionally, and socially supported. As hospital-based obstetric care providers, we do not always respect or meet these expectations. We can and should do better.

Women should not have to choose between a good birth experience and medical safety, between social support and hospital resources, between a sense of autonomy and access to life-saving interventions. Although every effort should be taken to make the birthing experience a positive one for the mother and her family as a whole, it should not be done at the expense of safety. I have yet to hear an asphyxiated and brain-damaged child thank his mother’s obstetric care provider for allowing a wonderful birth experience.

What this evidence means for practice
Even in countries where home births are integrated fully into the medical care system and attended by trained and certified nurse-midwives, they are associated with increased risks, including a twofold to threefold increase in the odds of neonatal death.4 In the US, where no such integration exists, home births are dangerous.

Maternity care has come a long way since the 17th Century, when a woman had a 1 in 6 chance of dying in childbirth and only one of every five children lived to enjoy a first birthday. It is appropriate in this era of Obamacare and cost containment that we explore alternative methods. The option of a safe home delivery may well be part of the solution, as it is for many European countries--but until we can be assured that such an approach is safe for both mothers and infants, let's keep home delivery where it belongs...for pizza!

--Errol R. Norwitz, MD, PHD

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