Health IT

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.¹

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.

The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.

Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.

The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.

A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.

Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.

Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.

At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).

Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.

SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.

“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Only a sliver of rural hospitals would meet the Center for Medicare & Medicaid Services’ (CMS) criteria to qualify for “meaningful use” of health information technology (HIT), according to a new study, but that could be a window for HM group leaders to take the reins of technology projects.

“[Hospitalists] could be very useful as a champion,” says Brock Slabach, MPH, FACHE, senior vice president for member services at the National Rural Health Association.

The new report showed that 5% of rural hospitals could demonstrate meaningful use of an electronic health record (EHR) system, as opposed to 9% of urban hospitals (J Rural Health. 2011;27(3):329-337). The number dips to 3% for critical-access hospitals. EHR usage often is used as a benchmark for HIT implementation.

CMS has allotted $20 billion for physicians and hospitals to adopt new technologies, but entities must prove they have met “meaningful use” requirements.

Slabach, who spent 20 years as an administrator at Field Memorial Community Hospital in Centreville, Miss., says the major hurdle for HIT implementation at rural hospitals is a lack of knowledge. But if hospitalists can show other physicians the value of HIT, others will follow, he adds.

“Somebody who may not have any informatics background, but is willing to grab a hold of the system, learn its applications, develop methods to spread the knowledge to the rest of the medical staff, is critical,” Slabach says. “It just takes that one or two [people] to get the momentum starting, in terms of a transition to what for a lot of middle-aged and older physicians is a completely new world.”

Only a sliver of rural hospitals would meet the Center for Medicare & Medicaid Services’ (CMS) criteria to qualify for “meaningful use” of health information technology (HIT), according to a new study, but that could be a window for HM group leaders to take the reins of technology projects.

“[Hospitalists] could be very useful as a champion,” says Brock Slabach, MPH, FACHE, senior vice president for member services at the National Rural Health Association.

The new report showed that 5% of rural hospitals could demonstrate meaningful use of an electronic health record (EHR) system, as opposed to 9% of urban hospitals (J Rural Health. 2011;27(3):329-337). The number dips to 3% for critical-access hospitals. EHR usage often is used as a benchmark for HIT implementation.

CMS has allotted $20 billion for physicians and hospitals to adopt new technologies, but entities must prove they have met “meaningful use” requirements.

Slabach, who spent 20 years as an administrator at Field Memorial Community Hospital in Centreville, Miss., says the major hurdle for HIT implementation at rural hospitals is a lack of knowledge. But if hospitalists can show other physicians the value of HIT, others will follow, he adds.

“Somebody who may not have any informatics background, but is willing to grab a hold of the system, learn its applications, develop methods to spread the knowledge to the rest of the medical staff, is critical,” Slabach says. “It just takes that one or two [people] to get the momentum starting, in terms of a transition to what for a lot of middle-aged and older physicians is a completely new world.”

Only a sliver of rural hospitals would meet the Center for Medicare & Medicaid Services’ (CMS) criteria to qualify for “meaningful use” of health information technology (HIT), according to a new study, but that could be a window for HM group leaders to take the reins of technology projects.

“[Hospitalists] could be very useful as a champion,” says Brock Slabach, MPH, FACHE, senior vice president for member services at the National Rural Health Association.

The new report showed that 5% of rural hospitals could demonstrate meaningful use of an electronic health record (EHR) system, as opposed to 9% of urban hospitals (J Rural Health. 2011;27(3):329-337). The number dips to 3% for critical-access hospitals. EHR usage often is used as a benchmark for HIT implementation.

CMS has allotted $20 billion for physicians and hospitals to adopt new technologies, but entities must prove they have met “meaningful use” requirements.

Slabach, who spent 20 years as an administrator at Field Memorial Community Hospital in Centreville, Miss., says the major hurdle for HIT implementation at rural hospitals is a lack of knowledge. But if hospitalists can show other physicians the value of HIT, others will follow, he adds.

“Somebody who may not have any informatics background, but is willing to grab a hold of the system, learn its applications, develop methods to spread the knowledge to the rest of the medical staff, is critical,” Slabach says. “It just takes that one or two [people] to get the momentum starting, in terms of a transition to what for a lot of middle-aged and older physicians is a completely new world.”

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.