Quality

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.

Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.

Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.

The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.

Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.

The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.

However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.

Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.

"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.

Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.

Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.

The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

Improving healthcare means taking an efficacious intervention from one setting and effectively implementing it somewhere else.

“It is this key element of adapting what works to new settings that sets improvement in contrast to clinical research. The study of these complex systems will therefore require different methods of inquiry,” according to a recently published paper in the International Journal for Quality in Health Care titled “How Do We Learn about Improving Health Care: A Call for a New Epistemological Paradigm.”

“In biomedical sciences, we’re used to a golden standard that is the randomized controlled trial,” says lead author M. Rashad Massoud, MD, MPH, senior vice president, Quality & Performance Institute, University Research Co., LLC. “Of course, the nature of what we’re trying to do does not lend itself to that type of evaluation. It means that we can’t have an either/or situation where we either continue as we are or we go to flip side—which then inhibits the very nature of improvement from taking place, which is very contextual, very much adaptive in nature. There has to be a happy medium in between, where we can continue to do the improvements without inhibiting them and, at the same time, improve the rigor of the work.”

A new framework for how we learn about improvement could help in the design, implementation, and evaluation of QI by strengthening attribution and better understanding variations in effectiveness in different contexts, the authors assert.

“This will in turn allow us to understand which activities, under which conditions, are most effective at achieving sustained results in health outcomes,” the authors write.

In seeking a new framework for learning about QI, the authors suggest that the following questions must be considered:

• Did the improvements work?
• Why did they work?
• How do we know that the results can be attributed to the changes made?
• How can we replicate them?

“I think hospitalists would probably welcome the idea that not only can they measure improvements in the work that they’re doing but can actually do that in a more rigorous way and actually attribute the results they’re getting to the work that they’re doing,” Dr. Massoud says.

Reference

1. Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M. How do we learn about improving health care: a call for a new epistemological paradigm. Intl J Quality Health Care. doi:10.1093/intqhc/mzw039.

Improving healthcare means taking an efficacious intervention from one setting and effectively implementing it somewhere else.

“It is this key element of adapting what works to new settings that sets improvement in contrast to clinical research. The study of these complex systems will therefore require different methods of inquiry,” according to a recently published paper in the International Journal for Quality in Health Care titled “How Do We Learn about Improving Health Care: A Call for a New Epistemological Paradigm.”

“In biomedical sciences, we’re used to a golden standard that is the randomized controlled trial,” says lead author M. Rashad Massoud, MD, MPH, senior vice president, Quality & Performance Institute, University Research Co., LLC. “Of course, the nature of what we’re trying to do does not lend itself to that type of evaluation. It means that we can’t have an either/or situation where we either continue as we are or we go to flip side—which then inhibits the very nature of improvement from taking place, which is very contextual, very much adaptive in nature. There has to be a happy medium in between, where we can continue to do the improvements without inhibiting them and, at the same time, improve the rigor of the work.”

A new framework for how we learn about improvement could help in the design, implementation, and evaluation of QI by strengthening attribution and better understanding variations in effectiveness in different contexts, the authors assert.

“This will in turn allow us to understand which activities, under which conditions, are most effective at achieving sustained results in health outcomes,” the authors write.

In seeking a new framework for learning about QI, the authors suggest that the following questions must be considered:

• Did the improvements work?
• Why did they work?
• How do we know that the results can be attributed to the changes made?
• How can we replicate them?

“I think hospitalists would probably welcome the idea that not only can they measure improvements in the work that they’re doing but can actually do that in a more rigorous way and actually attribute the results they’re getting to the work that they’re doing,” Dr. Massoud says.

Reference

1. Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M. How do we learn about improving health care: a call for a new epistemological paradigm. Intl J Quality Health Care. doi:10.1093/intqhc/mzw039.

Improving healthcare means taking an efficacious intervention from one setting and effectively implementing it somewhere else.

“It is this key element of adapting what works to new settings that sets improvement in contrast to clinical research. The study of these complex systems will therefore require different methods of inquiry,” according to a recently published paper in the International Journal for Quality in Health Care titled “How Do We Learn about Improving Health Care: A Call for a New Epistemological Paradigm.”

“In biomedical sciences, we’re used to a golden standard that is the randomized controlled trial,” says lead author M. Rashad Massoud, MD, MPH, senior vice president, Quality & Performance Institute, University Research Co., LLC. “Of course, the nature of what we’re trying to do does not lend itself to that type of evaluation. It means that we can’t have an either/or situation where we either continue as we are or we go to flip side—which then inhibits the very nature of improvement from taking place, which is very contextual, very much adaptive in nature. There has to be a happy medium in between, where we can continue to do the improvements without inhibiting them and, at the same time, improve the rigor of the work.”

A new framework for how we learn about improvement could help in the design, implementation, and evaluation of QI by strengthening attribution and better understanding variations in effectiveness in different contexts, the authors assert.

“This will in turn allow us to understand which activities, under which conditions, are most effective at achieving sustained results in health outcomes,” the authors write.

In seeking a new framework for learning about QI, the authors suggest that the following questions must be considered:

• Did the improvements work?
• Why did they work?
• How do we know that the results can be attributed to the changes made?
• How can we replicate them?

“I think hospitalists would probably welcome the idea that not only can they measure improvements in the work that they’re doing but can actually do that in a more rigorous way and actually attribute the results they’re getting to the work that they’re doing,” Dr. Massoud says.

Reference

1. Massoud MR, Barry D, Murphy A, Albrecht Y, Sax S, Parchman M. How do we learn about improving health care: a call for a new epistemological paradigm. Intl J Quality Health Care. doi:10.1093/intqhc/mzw039.

Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.

He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.

“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”

The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.

“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.

One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”

Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.

He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.

“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”

The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.

“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.

One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”

Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.

He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.

“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”

The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.

“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.

One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”