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Two Hospitalist Groups Join SHM's Hospital Medicine Exchange
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.
HMX: Two New Communities, Lots of New Conversations
More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.
The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.
And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.
Brendon Shank is SHM’s associate vice president of communications.
Data Mining Expert Explains Role Performance Tools Will Play in Future
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
The Why and How Data Mining Is Applicable to Hospital Medicine
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Learn How Best To Avoid Some of Data Mining’s Potential Pitfalls
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
Hospitalists as Industrial Engineers
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Hospitals Reap Potential of Data Mining
In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.
Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.
In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.
In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.
Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.
In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.
In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.
Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.
In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.
Hospitalist Groups Extract New Solutions Via Data Mining
One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.
As the healthcare industry tilts toward accountable care, pay for performance and an increasingly
cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.
Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”
So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.1 In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.
Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.
“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.
Practice Improvement
Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.
A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.
Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).
Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”
When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.
As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”
North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.
Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.
—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member
Slow—Construction Ahead
The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.
In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.
Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”
Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.
Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”
Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.
—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member
Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.
“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.
Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.
Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.
And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”
Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.
Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.
Bryn Nelson is a freelance medical writer in Seattle.
Physician Performance Aids
Company: The Advisory Board Company
Sample product: CRIMSON Continuum of Care
Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”
Number of users: More than 850 hospitals
Real-time data? No, but available as add-on service
To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care
Company: Panacea Developments
Sample product: Iodine
Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”
Number of users: More than 50 hospitals
Real-time data? Yes
To learn more: www.panaceadevelopments.com/iodine
Company: Truven Health
Sample product: CareDiscovery
Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”
Real-time data? No
Number of users: More than 3,000 users in 400 hospitals
To learn more: http://truvenhealth.com/products/carediscovery
Company: Ingenious Med
Sample product: Imagine
Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”
Real-time data? Yes
Number of users: 25,000 total users (not separated by individual products)
To learn more: http://ingeniousmed.com/what-we-do/imagine
Reference
One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.
As the healthcare industry tilts toward accountable care, pay for performance and an increasingly
cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.
Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”
So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.1 In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.
Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.
“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.
Practice Improvement
Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.
A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.
Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).
Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”
When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.
As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”
North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.
Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.
—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member
Slow—Construction Ahead
The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.
In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.
Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”
Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.
Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”
Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.
—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member
Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.
“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.
Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.
Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.
And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”
Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.
Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.
Bryn Nelson is a freelance medical writer in Seattle.
Physician Performance Aids
Company: The Advisory Board Company
Sample product: CRIMSON Continuum of Care
Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”
Number of users: More than 850 hospitals
Real-time data? No, but available as add-on service
To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care
Company: Panacea Developments
Sample product: Iodine
Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”
Number of users: More than 50 hospitals
Real-time data? Yes
To learn more: www.panaceadevelopments.com/iodine
Company: Truven Health
Sample product: CareDiscovery
Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”
Real-time data? No
Number of users: More than 3,000 users in 400 hospitals
To learn more: http://truvenhealth.com/products/carediscovery
Company: Ingenious Med
Sample product: Imagine
Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”
Real-time data? Yes
Number of users: 25,000 total users (not separated by individual products)
To learn more: http://ingeniousmed.com/what-we-do/imagine
Reference
One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.
As the healthcare industry tilts toward accountable care, pay for performance and an increasingly
cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.
Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”
So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.1 In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.
Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.
“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.
Practice Improvement
Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.
A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.
Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).
Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”
When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.
As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”
North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.
Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.
—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member
Slow—Construction Ahead
The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.
In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.
Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”
Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.
Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”
Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.
—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member
Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.
“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.
Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.
Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.
And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”
Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.
Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.
Bryn Nelson is a freelance medical writer in Seattle.
Physician Performance Aids
Company: The Advisory Board Company
Sample product: CRIMSON Continuum of Care
Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”
Number of users: More than 850 hospitals
Real-time data? No, but available as add-on service
To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care
Company: Panacea Developments
Sample product: Iodine
Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”
Number of users: More than 50 hospitals
Real-time data? Yes
To learn more: www.panaceadevelopments.com/iodine
Company: Truven Health
Sample product: CareDiscovery
Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”
Real-time data? No
Number of users: More than 3,000 users in 400 hospitals
To learn more: http://truvenhealth.com/products/carediscovery
Company: Ingenious Med
Sample product: Imagine
Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”
Real-time data? Yes
Number of users: 25,000 total users (not separated by individual products)
To learn more: http://ingeniousmed.com/what-we-do/imagine
Reference
Three Easy Ways to Get Ahead in Hospital Medicine
Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.
1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.
Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.
Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:
- Excellence in Research Award;
- Excellence in Hospital Medicine for Non-Physicians;
- Award for Excellence in Teaching;
- Award for Outstanding Service in Hospital Medicine;
- Award for Clinical Excellence; and
- Excellence in Teamwork in Quality Improvement.
Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.
The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.
For more information, visit www.hospital medicine.org/awards.
2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.
There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.
Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:
- A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
- A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
- Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
- Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
- The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.
For more information, visit www.hospital medicine.org/boost.
3. Start Choosing Wisely today.
In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.
But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.
To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.
Brendon Shank is SHM’s associate vice president of communications.
Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.
1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.
Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.
Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:
- Excellence in Research Award;
- Excellence in Hospital Medicine for Non-Physicians;
- Award for Excellence in Teaching;
- Award for Outstanding Service in Hospital Medicine;
- Award for Clinical Excellence; and
- Excellence in Teamwork in Quality Improvement.
Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.
The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.
For more information, visit www.hospital medicine.org/awards.
2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.
There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.
Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:
- A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
- A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
- Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
- Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
- The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.
For more information, visit www.hospital medicine.org/boost.
3. Start Choosing Wisely today.
In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.
But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.
To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.
Brendon Shank is SHM’s associate vice president of communications.
Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.
1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.
Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.
Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:
- Excellence in Research Award;
- Excellence in Hospital Medicine for Non-Physicians;
- Award for Excellence in Teaching;
- Award for Outstanding Service in Hospital Medicine;
- Award for Clinical Excellence; and
- Excellence in Teamwork in Quality Improvement.
Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.
The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.
For more information, visit www.hospital medicine.org/awards.
2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.
There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.
Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:
- A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
- A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
- Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
- Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
- The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.
For more information, visit www.hospital medicine.org/boost.
3. Start Choosing Wisely today.
In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.
But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.
To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.
Brendon Shank is SHM’s associate vice president of communications.
The Pros and Cons of Electronic Health Records
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
Preventative Measures
Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.
Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).4 For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.
More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.
References
- Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
- Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
- U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.
Commemorating Round-the-Clock Hospital Medicine Programs
The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.
Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.
Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.
To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.
I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.
Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?
Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.
Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?
A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.
Q: How did you convince the board of trustees to fund it?
A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.
Q: What was the most difficult operational challenge for the program?
A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.
Q: How was it received by patients?
A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.
Q: How did you get the medical staff to buy into the program?
A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.
Q: Are you surprised HM as a field has grown so quickly?
A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.
Q: What big challenges remain for hospital medicine? What are some solutions?
A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.
The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.
Final Thoughts
I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
(Editor's note: Updated July 12, 2013.)
The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.
Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.
Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.
To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.
I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.
Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?
Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.
Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?
A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.
Q: How did you convince the board of trustees to fund it?
A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.
Q: What was the most difficult operational challenge for the program?
A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.
Q: How was it received by patients?
A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.
Q: How did you get the medical staff to buy into the program?
A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.
Q: Are you surprised HM as a field has grown so quickly?
A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.
Q: What big challenges remain for hospital medicine? What are some solutions?
A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.
The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.
Final Thoughts
I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
(Editor's note: Updated July 12, 2013.)
The steam engine. The telephone. Television. ATMs. The Internet. Smartphones. The 24/7 hospitalist program.
Perhaps the single most important innovation along the road to where we are now in HM has been the development of the hospital-sponsored, 24/7, on-site hospitalist program. And the father of this invention may be the most significant figure in HM you’ve never heard of: John Holbrook, MD, FACEP. An emergency-medicine physician since the mid-1970s, Dr. Holbrook did something in July 1993 that was considered off the wall, yet proved to be revolutionary: From nothing, he launched a 24/7 hospitalist program staffed with board-eligible and board-certified internists at Mercy Hospital in Springfield, Mass. The inpatient physicians (this was before the word “hospitalist” came to be) were employed by a subsidiary of the hospital and worked in place of community primary-care physicians (PCPs), taking care of hospitalized patients who did not have a PCP, or whose PCP chose not to come to the hospital.
Of great significance, from the beginning, and perhaps by unintentional design, these physicians were agents of change and improvement for the hospital itself.
To be sure, in places like Southern California, 24/7, on-site hospitalist programs were in place in the late 1980s. Some claim those programs may have been the birthplace of the hospitalist model. However, such programs came to be in order to help medical groups manage full capitated risk delegated to them from HMOs on a population of patients, and were not supported by the hospital, per se. This is distinct from hospitalist programs—such as Mercy’s—sponsored by hospitals (whether employed or contracted) in predominantly fee-for-service markets, which then comprised the lion’s share of the U.S. market.
I had the extraordinary good fortune to happen along in July 1994, get hired by Dr. Holbrook, and soon after begin serving as medical director for the Mercy program, which I would do for the next decade. To this day, Dr. Holbrook is a mentor and trusted advisor to me. I caught up with him in recognition of the 20th anniversary of the Mercy Inpatient Medicine Service.
Question: What gave you the idea to launch what was, at the time, considered such an unconventional program?
Answer: Before the specialty of emergency medicine, a patient’s private physician would be called in most cases when a patient present in the ED: 25 or 50 doctors might be called over 24 hours, each to see one patient each. The inefficiency and disruption caused by this system was a natural and logical stimulus to develop the specialty of emergency medicine. I saw hospitalist medicine as an exact analogy.
Q: What were you observing in the healthcare environment that drove you to create the Mercy Inpatient Medicine Service?
A: Working for many years in the emergency department of a community hospital without a house staff, the ED docs would admit a patient at night or on the weekend and the attending physician would often plan to see the patient “in the morning.” When the patient would decompensate in the middle of the night, the ED doc would get a call to run to the floor to “Band-Aid” the situation.
Q: How did you convince the board of trustees to fund it?
A: The reasons were primarily economic. No. 1, the hospital was losing market share because local physicians would prefer to admit to the teaching hospital [a nearby competitor], where they were not required to come in during the middle of the night. No. 2, the cost of a hospitalization managed by a hospitalist was less expensive than either a hospital stay managed by house staff or managed over the telephone by a private attending at home.
Q: What was the most difficult operational challenge for the program?
A: Effective and timely communication with the community physicians was the most difficult operational challenge. Access to outpatient medical treatment immediately prior to a hospitalization and timely communication to the community physician were both challenges that we never adequately solved in the early days. I understand that these issues can still be problematic.
Q: How was it received by patients?
A: Overall, patients were very happy with the system. In the old system, with a typical four-physician practice, a patient had only a 1 in 4 chance of being admitted by the doctor who was familiar with the case. The fact that the hospitalist was available in the hospital made the improvement in quality apparent to most patients.
Q: How did you get the medical staff to buy into the program?
A: I personally visited every private physician who participated. Physicians were given the option of not participating, or of part-time participation—for example, on weekends or holidays only. The word spread. Physicians came up to me and told me that the program enabled them to continue practicing for another five years. Physicians’ spouses thanked me.
Q: Are you surprised HM as a field has grown so quickly?
A: I am not really that surprised. It is a better way to organize health care. I am surprised that it did not occur sooner. We talked about instituting this system for 10 years before 1993.
Q: What big challenges remain for hospital medicine? What are some solutions?
A: I believe that the biggest global challenge for hospital medicine remains communication with community-based providers, both before the hospitalization as well as during hospitalization and immediately after discharge. In the era of the EMR, the Internet, and the iPhone and Android, this should be easier. HIPAA has not helped.
The other growing challenge will become apparent as hospitalists age in the profession: Disruption of the diurnal sleep cycle becomes increasingly problematic for many physicians after the age of 50 and can easily lead to burnout. The early hospitalists were all in their 30s. The attractive lifestyle choice for the 30-year-old can lead to burnout for the 55-year-old. The emergency-medicine literature has noted a similar problem of shift work/sleep fragmentation.
Final Thoughts
I believe Dr. Holbrook’s assessments on the future of our specialty are on target. As HM continues to mature, we need to continue to focus on how we communicate with providers outside the four walls of the hospital and how to address barriers to making HM a sustainable career.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
(Editor's note: Updated July 12, 2013.)