Richard Quinn

GRAPEVINE, Texas—The president of the AMA told a packed house at HM11 this morning that pressure points on healthcare—physician shortages, rising medical school costs, and the impending addition of some 30 million-plus insured patients to the system – should spur doctors collaborate more to prevent mistakes and add efficiency.

And hospitalists can be right in the middle of it.

In an interview after his formal remarks, Cecil Wilson, MD, says that hospitalists are a key player, particularly in the workforce issues plaguing primary care physicians (PCP).

“Hospitalists are primary care physicians, the vast majority of them are general internists,” he says. “… so when we say that the number of people who are going into primary care, particularly general internal medicine, is reducing, that reduces not only the pool of physicians in the community, but also the hospitalist pool. We’re in that boat together.”

Dr. Wilson’s address, “A National Perspective for Hospitalists,” kicked off the official first day of SHM’s annual meeting with a global perspective of healthcare reform. The comments were followed by a detailed history of the healthcare debate that led to the Affordable Care Act last year, presented by Robert Kocher, MD, a former special assistant to President Obama and now the director of the McKinsey Center for U.S. Health System Reform in Washington, D.C.

Dr. Kocher says hospitalists can help healthcare deal with the reforms in four broad ways: push hospitals to increase labor productivity, shift compensation models from “selling work RVUs to selling years of health,” use data to drive decision-making and use technology to lower delivery costs.

With hospitalists’ “understanding of clinical medicine in a patient … you’ll be able to help them solve problems they never even imagined.”

GRAPEVINE, Texas—The president of the AMA told a packed house at HM11 this morning that pressure points on healthcare—physician shortages, rising medical school costs, and the impending addition of some 30 million-plus insured patients to the system – should spur doctors collaborate more to prevent mistakes and add efficiency.

And hospitalists can be right in the middle of it.

In an interview after his formal remarks, Cecil Wilson, MD, says that hospitalists are a key player, particularly in the workforce issues plaguing primary care physicians (PCP).

“Hospitalists are primary care physicians, the vast majority of them are general internists,” he says. “… so when we say that the number of people who are going into primary care, particularly general internal medicine, is reducing, that reduces not only the pool of physicians in the community, but also the hospitalist pool. We’re in that boat together.”

Dr. Wilson’s address, “A National Perspective for Hospitalists,” kicked off the official first day of SHM’s annual meeting with a global perspective of healthcare reform. The comments were followed by a detailed history of the healthcare debate that led to the Affordable Care Act last year, presented by Robert Kocher, MD, a former special assistant to President Obama and now the director of the McKinsey Center for U.S. Health System Reform in Washington, D.C.

Dr. Kocher says hospitalists can help healthcare deal with the reforms in four broad ways: push hospitals to increase labor productivity, shift compensation models from “selling work RVUs to selling years of health,” use data to drive decision-making and use technology to lower delivery costs.

With hospitalists’ “understanding of clinical medicine in a patient … you’ll be able to help them solve problems they never even imagined.”

GRAPEVINE, Texas—The president of the AMA told a packed house at HM11 this morning that pressure points on healthcare—physician shortages, rising medical school costs, and the impending addition of some 30 million-plus insured patients to the system – should spur doctors collaborate more to prevent mistakes and add efficiency.

And hospitalists can be right in the middle of it.

In an interview after his formal remarks, Cecil Wilson, MD, says that hospitalists are a key player, particularly in the workforce issues plaguing primary care physicians (PCP).

“Hospitalists are primary care physicians, the vast majority of them are general internists,” he says. “… so when we say that the number of people who are going into primary care, particularly general internal medicine, is reducing, that reduces not only the pool of physicians in the community, but also the hospitalist pool. We’re in that boat together.”

Dr. Wilson’s address, “A National Perspective for Hospitalists,” kicked off the official first day of SHM’s annual meeting with a global perspective of healthcare reform. The comments were followed by a detailed history of the healthcare debate that led to the Affordable Care Act last year, presented by Robert Kocher, MD, a former special assistant to President Obama and now the director of the McKinsey Center for U.S. Health System Reform in Washington, D.C.

Dr. Kocher says hospitalists can help healthcare deal with the reforms in four broad ways: push hospitals to increase labor productivity, shift compensation models from “selling work RVUs to selling years of health,” use data to drive decision-making and use technology to lower delivery costs.

With hospitalists’ “understanding of clinical medicine in a patient … you’ll be able to help them solve problems they never even imagined.”

GRAPEVINE, Texas – Hospitalist Gilbert Asomaning, MB, ChB, walked into a post-anesthesia care unit (PACU) this morning and was confronted with a 55-year-old male in shock. The monitor presented a myriad of issues: He was making lactate, had trouble urinating–and the familiar PACU beeping was incessant.

But no one knew why. Colleagues screamed out questions: Is he responsive? How are his extremities? Is he on oxygen? Still, the cause of what turned out to be hypovolemic shock was a mystery until someone said it: a pinned iliac artery. The case wasn't real; it was a simulation that was part of an HM11 pre-course at the Gaylord Texan Resort & Convention Center. But the value of the daylong session, "Advanced Interactive Critical Care," was quite real.

"This is a great session...it seems like the real thing, but here you know, you are hear to learn," says Dr. Asomaning, who has been to previous SHM meetings, but this year trekked out a day early from Capital Medical Center in Olympia, Wash., specifically to attend the critical care pre-course. "You go through it and when you make your mistakes, you are corrected. And then you sort of reorganize things in your mind again and you are more prepared when the real thing happens."

The simulation was led by course co-director Kevin Felner, MD, of New York University School of Medicine, who says supplementing lectures with hands-on situations is key to increased comprehension.

"Most people are learners by doing…and learn more from doing something than 45 minutes of lecture with a chalkboard," he says. "We push people, take them out of their comfort zone. That’s how you learn."

GRAPEVINE, Texas – Hospitalist Gilbert Asomaning, MB, ChB, walked into a post-anesthesia care unit (PACU) this morning and was confronted with a 55-year-old male in shock. The monitor presented a myriad of issues: He was making lactate, had trouble urinating–and the familiar PACU beeping was incessant.

But no one knew why. Colleagues screamed out questions: Is he responsive? How are his extremities? Is he on oxygen? Still, the cause of what turned out to be hypovolemic shock was a mystery until someone said it: a pinned iliac artery. The case wasn't real; it was a simulation that was part of an HM11 pre-course at the Gaylord Texan Resort & Convention Center. But the value of the daylong session, "Advanced Interactive Critical Care," was quite real.

"This is a great session...it seems like the real thing, but here you know, you are hear to learn," says Dr. Asomaning, who has been to previous SHM meetings, but this year trekked out a day early from Capital Medical Center in Olympia, Wash., specifically to attend the critical care pre-course. "You go through it and when you make your mistakes, you are corrected. And then you sort of reorganize things in your mind again and you are more prepared when the real thing happens."

The simulation was led by course co-director Kevin Felner, MD, of New York University School of Medicine, who says supplementing lectures with hands-on situations is key to increased comprehension.

"Most people are learners by doing…and learn more from doing something than 45 minutes of lecture with a chalkboard," he says. "We push people, take them out of their comfort zone. That’s how you learn."

GRAPEVINE, Texas – Hospitalist Gilbert Asomaning, MB, ChB, walked into a post-anesthesia care unit (PACU) this morning and was confronted with a 55-year-old male in shock. The monitor presented a myriad of issues: He was making lactate, had trouble urinating–and the familiar PACU beeping was incessant.

But no one knew why. Colleagues screamed out questions: Is he responsive? How are his extremities? Is he on oxygen? Still, the cause of what turned out to be hypovolemic shock was a mystery until someone said it: a pinned iliac artery. The case wasn't real; it was a simulation that was part of an HM11 pre-course at the Gaylord Texan Resort & Convention Center. But the value of the daylong session, "Advanced Interactive Critical Care," was quite real.

"This is a great session...it seems like the real thing, but here you know, you are hear to learn," says Dr. Asomaning, who has been to previous SHM meetings, but this year trekked out a day early from Capital Medical Center in Olympia, Wash., specifically to attend the critical care pre-course. "You go through it and when you make your mistakes, you are corrected. And then you sort of reorganize things in your mind again and you are more prepared when the real thing happens."

The simulation was led by course co-director Kevin Felner, MD, of New York University School of Medicine, who says supplementing lectures with hands-on situations is key to increased comprehension.

"Most people are learners by doing…and learn more from doing something than 45 minutes of lecture with a chalkboard," he says. "We push people, take them out of their comfort zone. That’s how you learn."

A newly implemented rule (PDF) requiring hospitalists and others who order home health services for Medicare patients to document face-to-face encounters has left SHM and other physician groups searching for clarity.

Under a Centers for Medicare & Medicaid Services (CMS) guideline that took effect April 1, physicians need to show proof of documentation before a patient can receive home care services. The documentation is known as a "certification form," and, either on the form or as an addendum to it, physicians must show that they either they saw the patient or allowed a nonphysician provider to do so. CMS is allowing such documentation (PDF) to be generated from an electronic health record.

Some industry watchers say that despite the deadline, many hospitalists are unaware of the rule. And many of those who are aware are confused as to whether any additional paperwork is required of them, creating the potential for an overwhelming paperwork burden being placed on hospitalists.

SHM and other professional societies, including the American Medical Association (AMA) and the American Hospital Association (AHA), asked CMS to delay the implementation until July 1, in the hopes that more time would help clear up any confusion. CMS declined.

In a letter to CMS Administrator Donald Berwick, MD, last month the AMA wrote, "it is our hope that CMS will reconsider its decision not to further delay the home health requirement and that in the future, imposition of policies … would be discussed with the medical profession BEFORE they turn up in a proposed rule." In addition, CMS needs to significantly improve its education efforts for physicians."

Ryan Genzink, PA-C, of IPC/Hospitalists of West Michigan in Grand Rapids says his hospital began using a new form just to document face-to-face encounters, until he learned from SHM that adding the information to existing documentation could satisfy the new rule. Genzink fears hospitalists around the country are operating under a patchwork of forms and guidelines, which can be a waste of time and money.

"The primary barrier to compliance is the paperwork burden on physicians," SHM and other trade groups wrote to CMS in March. "...The solution to the documentation concerns lies within CMS authority."

A newly implemented rule (PDF) requiring hospitalists and others who order home health services for Medicare patients to document face-to-face encounters has left SHM and other physician groups searching for clarity.

Under a Centers for Medicare & Medicaid Services (CMS) guideline that took effect April 1, physicians need to show proof of documentation before a patient can receive home care services. The documentation is known as a "certification form," and, either on the form or as an addendum to it, physicians must show that they either they saw the patient or allowed a nonphysician provider to do so. CMS is allowing such documentation (PDF) to be generated from an electronic health record.

Some industry watchers say that despite the deadline, many hospitalists are unaware of the rule. And many of those who are aware are confused as to whether any additional paperwork is required of them, creating the potential for an overwhelming paperwork burden being placed on hospitalists.

SHM and other professional societies, including the American Medical Association (AMA) and the American Hospital Association (AHA), asked CMS to delay the implementation until July 1, in the hopes that more time would help clear up any confusion. CMS declined.

In a letter to CMS Administrator Donald Berwick, MD, last month the AMA wrote, "it is our hope that CMS will reconsider its decision not to further delay the home health requirement and that in the future, imposition of policies … would be discussed with the medical profession BEFORE they turn up in a proposed rule." In addition, CMS needs to significantly improve its education efforts for physicians."

Ryan Genzink, PA-C, of IPC/Hospitalists of West Michigan in Grand Rapids says his hospital began using a new form just to document face-to-face encounters, until he learned from SHM that adding the information to existing documentation could satisfy the new rule. Genzink fears hospitalists around the country are operating under a patchwork of forms and guidelines, which can be a waste of time and money.

"The primary barrier to compliance is the paperwork burden on physicians," SHM and other trade groups wrote to CMS in March. "...The solution to the documentation concerns lies within CMS authority."

A newly implemented rule (PDF) requiring hospitalists and others who order home health services for Medicare patients to document face-to-face encounters has left SHM and other physician groups searching for clarity.

Under a Centers for Medicare & Medicaid Services (CMS) guideline that took effect April 1, physicians need to show proof of documentation before a patient can receive home care services. The documentation is known as a "certification form," and, either on the form or as an addendum to it, physicians must show that they either they saw the patient or allowed a nonphysician provider to do so. CMS is allowing such documentation (PDF) to be generated from an electronic health record.

Some industry watchers say that despite the deadline, many hospitalists are unaware of the rule. And many of those who are aware are confused as to whether any additional paperwork is required of them, creating the potential for an overwhelming paperwork burden being placed on hospitalists.

SHM and other professional societies, including the American Medical Association (AMA) and the American Hospital Association (AHA), asked CMS to delay the implementation until July 1, in the hopes that more time would help clear up any confusion. CMS declined.

In a letter to CMS Administrator Donald Berwick, MD, last month the AMA wrote, "it is our hope that CMS will reconsider its decision not to further delay the home health requirement and that in the future, imposition of policies … would be discussed with the medical profession BEFORE they turn up in a proposed rule." In addition, CMS needs to significantly improve its education efforts for physicians."

Ryan Genzink, PA-C, of IPC/Hospitalists of West Michigan in Grand Rapids says his hospital began using a new form just to document face-to-face encounters, until he learned from SHM that adding the information to existing documentation could satisfy the new rule. Genzink fears hospitalists around the country are operating under a patchwork of forms and guidelines, which can be a waste of time and money.

"The primary barrier to compliance is the paperwork burden on physicians," SHM and other trade groups wrote to CMS in March. "...The solution to the documentation concerns lies within CMS authority."

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

“For the specialty, it brings identity and awareness of all that we do,” Erin Stucky Fisher, MD, MHM, a pediatric hospitalist at Rady Children’s Hospital in San Diego, wrote in an email. “We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day.”

The other MHMs spoke to The Hospitalist in the April 13 TH eWire:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM’s Public Policy Committee, says “I’ve had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field.

“To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty.”

Russell L. Holman, MD, MHM, Cogent’s COO and past president of SHM, says “our specialty is constantly evolving; there is no paved road before us. We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me.”

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, says “it is a terrific honor to be recognized by SHM in this way. The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!”

SHM has now recognized seven MHMs. The first class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM.

Each Master in HM is recognized for what SHM says is the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.” TH

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

“For the specialty, it brings identity and awareness of all that we do,” Erin Stucky Fisher, MD, MHM, a pediatric hospitalist at Rady Children’s Hospital in San Diego, wrote in an email. “We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day.”

The other MHMs spoke to The Hospitalist in the April 13 TH eWire:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM’s Public Policy Committee, says “I’ve had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field.

“To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty.”

Russell L. Holman, MD, MHM, Cogent’s COO and past president of SHM, says “our specialty is constantly evolving; there is no paved road before us. We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me.”

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, says “it is a terrific honor to be recognized by SHM in this way. The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!”

SHM has now recognized seven MHMs. The first class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM.

Each Master in HM is recognized for what SHM says is the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.” TH

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

“For the specialty, it brings identity and awareness of all that we do,” Erin Stucky Fisher, MD, MHM, a pediatric hospitalist at Rady Children’s Hospital in San Diego, wrote in an email. “We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day.”

The other MHMs spoke to The Hospitalist in the April 13 TH eWire:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM’s Public Policy Committee, says “I’ve had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field.

“To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty.”

Russell L. Holman, MD, MHM, Cogent’s COO and past president of SHM, says “our specialty is constantly evolving; there is no paved road before us. We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me.”

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, says “it is a terrific honor to be recognized by SHM in this way. The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!”

SHM has now recognized seven MHMs. The first class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM.

Each Master in HM is recognized for what SHM says is the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.” TH

A risk-stratification tool is a first step for hospitalists and others trying to identify patients with sufficient VTE risk to warrant pharmacological prophylaxis, according to a new Journal of Hospital Medicine report.

The authors of the retrospective cohort study noted that while both the American College of Chest Physicians (ACCP) and the Joint Commission mandate inpatients can be assessed for VTE risk, there are no validated risk-stratification tools. So a team of researchers from Baystate Medical Center in Springfield, Mass., and Tufts University School of Medicine in Boston reviewed patients with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection. Length of stay had to be greater than three days.

The authors reported the strongest risk factors were inherited thrombophilia (OR 4.00), length of stay equal to or greater than six days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. But more research needs to be done to determine exactly what risk levels should trigger the use of prophylaxis, says lead author Michael Rothberg, MD, MPH, associate professor of medicine at Tufts and Baystate's interim chief of the Division of General Medicine.

"I would hope people would use the model as a way to measure a patient's risk," says Dr. Rothberg, who also serves as Baystate's director of scholarly activities in the Internal Medicine Training Program. "The problem is, we don't know the threshold."

Dr. Rothberg and his colleagues are currently preparing a grant application to take the next step in the research, which would be an attempt to define just what risk levels in patients should trigger pharmacological prophylaxis. While such treatments, including the use of heparin, have relatively low risks for patients, "the costs are real," Dr. Rothberg says.

In the meantime, he says, the take-home message from his team's preliminary work is that without accepted risk thresholds in place, physicians should determine prophylaxis use on a patient-by-patient basis.

"There's a need for a more nuanced approach," he says. "It's a not a one-size-fits-all."

A risk-stratification tool is a first step for hospitalists and others trying to identify patients with sufficient VTE risk to warrant pharmacological prophylaxis, according to a new Journal of Hospital Medicine report.

The authors of the retrospective cohort study noted that while both the American College of Chest Physicians (ACCP) and the Joint Commission mandate inpatients can be assessed for VTE risk, there are no validated risk-stratification tools. So a team of researchers from Baystate Medical Center in Springfield, Mass., and Tufts University School of Medicine in Boston reviewed patients with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection. Length of stay had to be greater than three days.

The authors reported the strongest risk factors were inherited thrombophilia (OR 4.00), length of stay equal to or greater than six days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. But more research needs to be done to determine exactly what risk levels should trigger the use of prophylaxis, says lead author Michael Rothberg, MD, MPH, associate professor of medicine at Tufts and Baystate's interim chief of the Division of General Medicine.

"I would hope people would use the model as a way to measure a patient's risk," says Dr. Rothberg, who also serves as Baystate's director of scholarly activities in the Internal Medicine Training Program. "The problem is, we don't know the threshold."

Dr. Rothberg and his colleagues are currently preparing a grant application to take the next step in the research, which would be an attempt to define just what risk levels in patients should trigger pharmacological prophylaxis. While such treatments, including the use of heparin, have relatively low risks for patients, "the costs are real," Dr. Rothberg says.

In the meantime, he says, the take-home message from his team's preliminary work is that without accepted risk thresholds in place, physicians should determine prophylaxis use on a patient-by-patient basis.

"There's a need for a more nuanced approach," he says. "It's a not a one-size-fits-all."

A risk-stratification tool is a first step for hospitalists and others trying to identify patients with sufficient VTE risk to warrant pharmacological prophylaxis, according to a new Journal of Hospital Medicine report.

The authors of the retrospective cohort study noted that while both the American College of Chest Physicians (ACCP) and the Joint Commission mandate inpatients can be assessed for VTE risk, there are no validated risk-stratification tools. So a team of researchers from Baystate Medical Center in Springfield, Mass., and Tufts University School of Medicine in Boston reviewed patients with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection. Length of stay had to be greater than three days.

The authors reported the strongest risk factors were inherited thrombophilia (OR 4.00), length of stay equal to or greater than six days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. But more research needs to be done to determine exactly what risk levels should trigger the use of prophylaxis, says lead author Michael Rothberg, MD, MPH, associate professor of medicine at Tufts and Baystate's interim chief of the Division of General Medicine.

"I would hope people would use the model as a way to measure a patient's risk," says Dr. Rothberg, who also serves as Baystate's director of scholarly activities in the Internal Medicine Training Program. "The problem is, we don't know the threshold."

Dr. Rothberg and his colleagues are currently preparing a grant application to take the next step in the research, which would be an attempt to define just what risk levels in patients should trigger pharmacological prophylaxis. While such treatments, including the use of heparin, have relatively low risks for patients, "the costs are real," Dr. Rothberg says.

In the meantime, he says, the take-home message from his team's preliminary work is that without accepted risk thresholds in place, physicians should determine prophylaxis use on a patient-by-patient basis.

"There's a need for a more nuanced approach," he says. "It's a not a one-size-fits-all."

Academic hospitalists earn less than their nonacademic counterparts, but they appear to earn more per work RVU, according to new data from SHM and the Medical Group Management Association (MGMA).

Compensation and productivity information, dubbed the 2011 Academic Practice Compensation and Production Module, is currently available via MGMA's website, but a more detailed review of academic hospitalists will be included in the annual State of Hospital Medicine report this summer.

The recently released data show the national median salary for an academic hospitalist in internal medicine is $173,113. National median productivity for all academic faculty, standardized to 100% billable clinical activity, is 3,365 wRVUs.

By comparison, median compensation for community hospitalists is $215,000 annually, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data. The 2010 report also pegged the median number of work RVUs at 4,107 per hospitalist per year.

"It doesn't surprise me salaries are lower," says Grace Huang, MD, staff hospitalist at Beth Israel Deaconess and assistant professor of medicine at Harvard Medical School, both in Boston. "I knew that choosing the life of an academic hospitalist."

In fact, Dr. Huang notes, capturing productivity for academicians is particularly tricky as activities like mentorship are difficult to quantify. She also cautions against reading too much into statistics, as "I'm a measurement person, so you can always make the data look different."

"When I look at my job as an academic hospitalist, clinical care is just part of it," adds Dr. Huang, who is among the group of hospitalists helping SHM scrub the data to be released this summer. "We have very different aspects of the job that are not easily represented in RVUs."

Academic hospitalists earn less than their nonacademic counterparts, but they appear to earn more per work RVU, according to new data from SHM and the Medical Group Management Association (MGMA).

Compensation and productivity information, dubbed the 2011 Academic Practice Compensation and Production Module, is currently available via MGMA's website, but a more detailed review of academic hospitalists will be included in the annual State of Hospital Medicine report this summer.

The recently released data show the national median salary for an academic hospitalist in internal medicine is $173,113. National median productivity for all academic faculty, standardized to 100% billable clinical activity, is 3,365 wRVUs.

By comparison, median compensation for community hospitalists is $215,000 annually, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data. The 2010 report also pegged the median number of work RVUs at 4,107 per hospitalist per year.

"It doesn't surprise me salaries are lower," says Grace Huang, MD, staff hospitalist at Beth Israel Deaconess and assistant professor of medicine at Harvard Medical School, both in Boston. "I knew that choosing the life of an academic hospitalist."

In fact, Dr. Huang notes, capturing productivity for academicians is particularly tricky as activities like mentorship are difficult to quantify. She also cautions against reading too much into statistics, as "I'm a measurement person, so you can always make the data look different."

"When I look at my job as an academic hospitalist, clinical care is just part of it," adds Dr. Huang, who is among the group of hospitalists helping SHM scrub the data to be released this summer. "We have very different aspects of the job that are not easily represented in RVUs."

Academic hospitalists earn less than their nonacademic counterparts, but they appear to earn more per work RVU, according to new data from SHM and the Medical Group Management Association (MGMA).

Compensation and productivity information, dubbed the 2011 Academic Practice Compensation and Production Module, is currently available via MGMA's website, but a more detailed review of academic hospitalists will be included in the annual State of Hospital Medicine report this summer.

The recently released data show the national median salary for an academic hospitalist in internal medicine is $173,113. National median productivity for all academic faculty, standardized to 100% billable clinical activity, is 3,365 wRVUs.

By comparison, median compensation for community hospitalists is $215,000 annually, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data. The 2010 report also pegged the median number of work RVUs at 4,107 per hospitalist per year.

"It doesn't surprise me salaries are lower," says Grace Huang, MD, staff hospitalist at Beth Israel Deaconess and assistant professor of medicine at Harvard Medical School, both in Boston. "I knew that choosing the life of an academic hospitalist."

In fact, Dr. Huang notes, capturing productivity for academicians is particularly tricky as activities like mentorship are difficult to quantify. She also cautions against reading too much into statistics, as "I'm a measurement person, so you can always make the data look different."

"When I look at my job as an academic hospitalist, clinical care is just part of it," adds Dr. Huang, who is among the group of hospitalists helping SHM scrub the data to be released this summer. "We have very different aspects of the job that are not easily represented in RVUs."

As the healthcare industry digests the Centers for Medicare & Medicaid Services’ (CMS) proposed regulations on accountable care organizations (ACOs), a leading hospitalist wants to ensure that physicians are duly compensated for risk in the process.

An ACO is a type of healthcare delivery model being piloted by CMS in which a group of providers band together to coordinate the care of beneficiaries. Reimbursement is shared by the group and is tied to the quality of care provided.

Under rules released March 31 and published in the Federal Register (PDF) last week, ACOs can enter a shared savings or a shared savings/losses model. According to Becker's Hospital Review, in the shared savings model, also called a "one-sided model," an ACO that creates at least 2% savings is then entitled to 50% of the revenue above that amount. The shared savings/losses construct, known as a "two-sided model," entitles an ACO to 60% of the threshold, but also penalizes them if the model increase costs, the review says.

"You can certainly start by taking a lower amount of risk, just upside risk," says Ron Greeno, MD, FCCP, SFHM, chief medical officer for Brentwood, Tenn.-based Cogent Healthcare and a senior member of SHM's Public Policy Committee. "But your plan should be not to stay there. Your plan should be to take more and more risk as soon as you can, as soon as you're capable."

By the third year of the program, all ACOs would become responsible for losses.

"I didn't see a lot with capitated risk," Dr. Greeno says. "That's where the opportunity is for providers. That's the opportunity to create the most savings in Medicare."

CMS will take comments on the proposed regulations until the first week of June. The program is set to go live Jan. 1, 2012.

As the healthcare industry digests the Centers for Medicare & Medicaid Services’ (CMS) proposed regulations on accountable care organizations (ACOs), a leading hospitalist wants to ensure that physicians are duly compensated for risk in the process.

An ACO is a type of healthcare delivery model being piloted by CMS in which a group of providers band together to coordinate the care of beneficiaries. Reimbursement is shared by the group and is tied to the quality of care provided.

Under rules released March 31 and published in the Federal Register (PDF) last week, ACOs can enter a shared savings or a shared savings/losses model. According to Becker's Hospital Review, in the shared savings model, also called a "one-sided model," an ACO that creates at least 2% savings is then entitled to 50% of the revenue above that amount. The shared savings/losses construct, known as a "two-sided model," entitles an ACO to 60% of the threshold, but also penalizes them if the model increase costs, the review says.

"You can certainly start by taking a lower amount of risk, just upside risk," says Ron Greeno, MD, FCCP, SFHM, chief medical officer for Brentwood, Tenn.-based Cogent Healthcare and a senior member of SHM's Public Policy Committee. "But your plan should be not to stay there. Your plan should be to take more and more risk as soon as you can, as soon as you're capable."

By the third year of the program, all ACOs would become responsible for losses.

"I didn't see a lot with capitated risk," Dr. Greeno says. "That's where the opportunity is for providers. That's the opportunity to create the most savings in Medicare."

CMS will take comments on the proposed regulations until the first week of June. The program is set to go live Jan. 1, 2012.

As the healthcare industry digests the Centers for Medicare & Medicaid Services’ (CMS) proposed regulations on accountable care organizations (ACOs), a leading hospitalist wants to ensure that physicians are duly compensated for risk in the process.

An ACO is a type of healthcare delivery model being piloted by CMS in which a group of providers band together to coordinate the care of beneficiaries. Reimbursement is shared by the group and is tied to the quality of care provided.

Under rules released March 31 and published in the Federal Register (PDF) last week, ACOs can enter a shared savings or a shared savings/losses model. According to Becker's Hospital Review, in the shared savings model, also called a "one-sided model," an ACO that creates at least 2% savings is then entitled to 50% of the revenue above that amount. The shared savings/losses construct, known as a "two-sided model," entitles an ACO to 60% of the threshold, but also penalizes them if the model increase costs, the review says.

"You can certainly start by taking a lower amount of risk, just upside risk," says Ron Greeno, MD, FCCP, SFHM, chief medical officer for Brentwood, Tenn.-based Cogent Healthcare and a senior member of SHM's Public Policy Committee. "But your plan should be not to stay there. Your plan should be to take more and more risk as soon as you can, as soon as you're capable."

By the third year of the program, all ACOs would become responsible for losses.

"I didn't see a lot with capitated risk," Dr. Greeno says. "That's where the opportunity is for providers. That's the opportunity to create the most savings in Medicare."

CMS will take comments on the proposed regulations until the first week of June. The program is set to go live Jan. 1, 2012.

The greatest impact of new guidelines from the American Heart Association (AHA) that suggest additional therapies for treatment of more serious cases of DVT might be in prodding HM leaders to take ownership of existing standards to ensure greater compliance.

The review aims to help doctors "identify the severity of these disorders and to select who might be eligible for more invasive therapies, such as clot-busting drugs, catheter-based treatments or surgery," M. Sean McMurtry, MD, PhD, co-chair of the writing group said in a prepared statement. The guidelines outline multiple treatment options, including the use of fibrinolytic drugs, catheter-based interventions, treatment with surgery to remove the blood clots and use of filters. Additional guidance for treating pediatric patients is included.

But Gregory A. Maynard, MD, SFHM, hospital medicine division chief at the University of California at San Diego, says most hospitalists deal with more routine cases of DVT and VTE than the research paper highlights. Physicians need to take more control of the existing patchwork of guidelines recommended by various research and established protocols, he adds.

"What's missing in this paper ... is how to make those things happen more reliably," Dr. Maynard says. "To me, the hospitalist needs to look at guidelines like this and say, 'How can we make them happen reliably?'"

For example, Dr. Maynard notes that for the treatment of iliofemoral DVT, it is recommended to both overlap warfarin and heparin, as well as have patients wear elastic compression stockings. Yet, he says, neither of those recommendations is routinely followed. In fact, he says of the former: "I would guess the percentage of patients getting these stockings is a distinct minority."

And while that kind of reliability is tough to guarantee, it's one of the cornerstones of SHM's VTE prevention resource room and mentored implementation program.

The greatest impact of new guidelines from the American Heart Association (AHA) that suggest additional therapies for treatment of more serious cases of DVT might be in prodding HM leaders to take ownership of existing standards to ensure greater compliance.

The review aims to help doctors "identify the severity of these disorders and to select who might be eligible for more invasive therapies, such as clot-busting drugs, catheter-based treatments or surgery," M. Sean McMurtry, MD, PhD, co-chair of the writing group said in a prepared statement. The guidelines outline multiple treatment options, including the use of fibrinolytic drugs, catheter-based interventions, treatment with surgery to remove the blood clots and use of filters. Additional guidance for treating pediatric patients is included.

But Gregory A. Maynard, MD, SFHM, hospital medicine division chief at the University of California at San Diego, says most hospitalists deal with more routine cases of DVT and VTE than the research paper highlights. Physicians need to take more control of the existing patchwork of guidelines recommended by various research and established protocols, he adds.

"What's missing in this paper ... is how to make those things happen more reliably," Dr. Maynard says. "To me, the hospitalist needs to look at guidelines like this and say, 'How can we make them happen reliably?'"

For example, Dr. Maynard notes that for the treatment of iliofemoral DVT, it is recommended to both overlap warfarin and heparin, as well as have patients wear elastic compression stockings. Yet, he says, neither of those recommendations is routinely followed. In fact, he says of the former: "I would guess the percentage of patients getting these stockings is a distinct minority."

And while that kind of reliability is tough to guarantee, it's one of the cornerstones of SHM's VTE prevention resource room and mentored implementation program.

The greatest impact of new guidelines from the American Heart Association (AHA) that suggest additional therapies for treatment of more serious cases of DVT might be in prodding HM leaders to take ownership of existing standards to ensure greater compliance.

The review aims to help doctors "identify the severity of these disorders and to select who might be eligible for more invasive therapies, such as clot-busting drugs, catheter-based treatments or surgery," M. Sean McMurtry, MD, PhD, co-chair of the writing group said in a prepared statement. The guidelines outline multiple treatment options, including the use of fibrinolytic drugs, catheter-based interventions, treatment with surgery to remove the blood clots and use of filters. Additional guidance for treating pediatric patients is included.

But Gregory A. Maynard, MD, SFHM, hospital medicine division chief at the University of California at San Diego, says most hospitalists deal with more routine cases of DVT and VTE than the research paper highlights. Physicians need to take more control of the existing patchwork of guidelines recommended by various research and established protocols, he adds.

"What's missing in this paper ... is how to make those things happen more reliably," Dr. Maynard says. "To me, the hospitalist needs to look at guidelines like this and say, 'How can we make them happen reliably?'"

For example, Dr. Maynard notes that for the treatment of iliofemoral DVT, it is recommended to both overlap warfarin and heparin, as well as have patients wear elastic compression stockings. Yet, he says, neither of those recommendations is routinely followed. In fact, he says of the former: "I would guess the percentage of patients getting these stockings is a distinct minority."

And while that kind of reliability is tough to guarantee, it's one of the cornerstones of SHM's VTE prevention resource room and mentored implementation program.

After five years in the department of otolaryngology/head and neck surgery at the University of California at San Francisco (UCSF), Matthew Russell, MD, is joining the faculty as an assistant professor. Normally, such a career arc is commonplace. But Dr. Russell’s new job title—ENT hospitalist—is worth noting. In fact, it could be groundbreaking.

When Dr. Russell begins work this summer, he might be the only otolaryngologist in the country whose entire patient census and surgical pipeline will be generated by admissions to his hospital. Although there are otolaryngologists around the country who spend the majority of their time working with inpatients, nearly all work an clinical outpatient service as well.

“The hospitalist model turns the traditional ENT practice on its head,” Dr. Russell says. “An otolaryngology practice we think of as being centered around the clinic, and the clinic and referrals is where we generate our operative cases and our patient load. The question really becomes: Can you sustain a practice without a clinic-based model?”

David Nielsen, MD, executive vice president and CEO of the American Academy of Otolaryngology-Head and Neck Surgery, says that while there is no current groundswell for the model, he can envision physicians being drawn to it for two reasons: an aging cohort of otolaryngologists and younger physicians looking for work-life balance.

The hospitalist model turns the traditional ENT practice on its head.

—Matthew Russell, MD, oto-hospitalist, University of California at San Francisco

And while the otolaryngology world at large has not yet answered in unison, the presence of what some are calling an oto-hospitalist is the latest in a series of what HM pioneer Robert Wachter, MD, MHM, has termed “hyphenated hospitalists.” Dr. Wachter, chief of hospital medicine and chief of the medical service at UCSF Medical Center, a former SHM board member, and author of the Wachter’s World blog, says the needs of otolaryngology present the same set of circumstances that allowed internal-medicine-based HM to flourish.

“The forces,” Dr. Wachter wrote in January on his blog, “are the same: sick patients, highly specialized providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement.”

But just adding hospitalist to a job title is not the mark of HM’s presence.

“You can have any hyphenated medical specialist managing patients, but the question is, What are you getting out of it as a hospital or a hospitalist, or as an institution?” adds Gulshan Sharma MD, MPH, associate professor at the University of Texas Medical Branch at Galveston. “The hospitalists really have to figure out their boundaries.”

Dr. Russell says some physicians could be dismissive of the idea of an oto-hospitalist because they’re not clear about the role. They might picture a glorified resident constantly walking between wards to serve as a secondary opinion for other specialists. “There is a perception that this may not be a glamorous position,” he adds. “There’s an assumption that the position is nonsurgical.”

Dr. Russell’s workflow will include rounding and consultations across different wards, and he will assist with complex airway issues. But he also will perform surgeries and work on quality-improvement (QI) initiatives. For those who doubt the variety that a purely inpatient setting can deliver, Dr. Russell eagerly quotes statistics from a two-year pilot program UCSF ran before hiring him as a full-time ENT hospitalist:

• 300 inpatient consultations the first year, not including ED and urgent care;
• Sinonasal and laryngotracheal were the most common consults;
• 200 procedures generated billings; and
• 45% of procedures were laryngotracheal, 33% were sinonasal/anterior skull base, and 10% were otologic.

"The hospitalist movement, in general, fills a need for the acute-care setting and manages a different set of problems than is seen in the ambulatory clinics,” Dr. Russell says. “That same basic issue is found in otolaryngology. I think it’s an area that is perhaps underappreciated.”

Richard Quinn is a freelance writer based in New Jersey.

After five years in the department of otolaryngology/head and neck surgery at the University of California at San Francisco (UCSF), Matthew Russell, MD, is joining the faculty as an assistant professor. Normally, such a career arc is commonplace. But Dr. Russell’s new job title—ENT hospitalist—is worth noting. In fact, it could be groundbreaking.

When Dr. Russell begins work this summer, he might be the only otolaryngologist in the country whose entire patient census and surgical pipeline will be generated by admissions to his hospital. Although there are otolaryngologists around the country who spend the majority of their time working with inpatients, nearly all work an clinical outpatient service as well.

“The hospitalist model turns the traditional ENT practice on its head,” Dr. Russell says. “An otolaryngology practice we think of as being centered around the clinic, and the clinic and referrals is where we generate our operative cases and our patient load. The question really becomes: Can you sustain a practice without a clinic-based model?”

David Nielsen, MD, executive vice president and CEO of the American Academy of Otolaryngology-Head and Neck Surgery, says that while there is no current groundswell for the model, he can envision physicians being drawn to it for two reasons: an aging cohort of otolaryngologists and younger physicians looking for work-life balance.

The hospitalist model turns the traditional ENT practice on its head.

—Matthew Russell, MD, oto-hospitalist, University of California at San Francisco

And while the otolaryngology world at large has not yet answered in unison, the presence of what some are calling an oto-hospitalist is the latest in a series of what HM pioneer Robert Wachter, MD, MHM, has termed “hyphenated hospitalists.” Dr. Wachter, chief of hospital medicine and chief of the medical service at UCSF Medical Center, a former SHM board member, and author of the Wachter’s World blog, says the needs of otolaryngology present the same set of circumstances that allowed internal-medicine-based HM to flourish.

“The forces,” Dr. Wachter wrote in January on his blog, “are the same: sick patients, highly specialized providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement.”

But just adding hospitalist to a job title is not the mark of HM’s presence.

“You can have any hyphenated medical specialist managing patients, but the question is, What are you getting out of it as a hospital or a hospitalist, or as an institution?” adds Gulshan Sharma MD, MPH, associate professor at the University of Texas Medical Branch at Galveston. “The hospitalists really have to figure out their boundaries.”

Dr. Russell says some physicians could be dismissive of the idea of an oto-hospitalist because they’re not clear about the role. They might picture a glorified resident constantly walking between wards to serve as a secondary opinion for other specialists. “There is a perception that this may not be a glamorous position,” he adds. “There’s an assumption that the position is nonsurgical.”

Dr. Russell’s workflow will include rounding and consultations across different wards, and he will assist with complex airway issues. But he also will perform surgeries and work on quality-improvement (QI) initiatives. For those who doubt the variety that a purely inpatient setting can deliver, Dr. Russell eagerly quotes statistics from a two-year pilot program UCSF ran before hiring him as a full-time ENT hospitalist:

• 300 inpatient consultations the first year, not including ED and urgent care;
• Sinonasal and laryngotracheal were the most common consults;
• 200 procedures generated billings; and
• 45% of procedures were laryngotracheal, 33% were sinonasal/anterior skull base, and 10% were otologic.

"The hospitalist movement, in general, fills a need for the acute-care setting and manages a different set of problems than is seen in the ambulatory clinics,” Dr. Russell says. “That same basic issue is found in otolaryngology. I think it’s an area that is perhaps underappreciated.”

Richard Quinn is a freelance writer based in New Jersey.

After five years in the department of otolaryngology/head and neck surgery at the University of California at San Francisco (UCSF), Matthew Russell, MD, is joining the faculty as an assistant professor. Normally, such a career arc is commonplace. But Dr. Russell’s new job title—ENT hospitalist—is worth noting. In fact, it could be groundbreaking.

When Dr. Russell begins work this summer, he might be the only otolaryngologist in the country whose entire patient census and surgical pipeline will be generated by admissions to his hospital. Although there are otolaryngologists around the country who spend the majority of their time working with inpatients, nearly all work an clinical outpatient service as well.

“The hospitalist model turns the traditional ENT practice on its head,” Dr. Russell says. “An otolaryngology practice we think of as being centered around the clinic, and the clinic and referrals is where we generate our operative cases and our patient load. The question really becomes: Can you sustain a practice without a clinic-based model?”

David Nielsen, MD, executive vice president and CEO of the American Academy of Otolaryngology-Head and Neck Surgery, says that while there is no current groundswell for the model, he can envision physicians being drawn to it for two reasons: an aging cohort of otolaryngologists and younger physicians looking for work-life balance.

The hospitalist model turns the traditional ENT practice on its head.

—Matthew Russell, MD, oto-hospitalist, University of California at San Francisco

And while the otolaryngology world at large has not yet answered in unison, the presence of what some are calling an oto-hospitalist is the latest in a series of what HM pioneer Robert Wachter, MD, MHM, has termed “hyphenated hospitalists.” Dr. Wachter, chief of hospital medicine and chief of the medical service at UCSF Medical Center, a former SHM board member, and author of the Wachter’s World blog, says the needs of otolaryngology present the same set of circumstances that allowed internal-medicine-based HM to flourish.

“The forces,” Dr. Wachter wrote in January on his blog, “are the same: sick patients, highly specialized providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement.”

But just adding hospitalist to a job title is not the mark of HM’s presence.

“You can have any hyphenated medical specialist managing patients, but the question is, What are you getting out of it as a hospital or a hospitalist, or as an institution?” adds Gulshan Sharma MD, MPH, associate professor at the University of Texas Medical Branch at Galveston. “The hospitalists really have to figure out their boundaries.”

Dr. Russell says some physicians could be dismissive of the idea of an oto-hospitalist because they’re not clear about the role. They might picture a glorified resident constantly walking between wards to serve as a secondary opinion for other specialists. “There is a perception that this may not be a glamorous position,” he adds. “There’s an assumption that the position is nonsurgical.”

Dr. Russell’s workflow will include rounding and consultations across different wards, and he will assist with complex airway issues. But he also will perform surgeries and work on quality-improvement (QI) initiatives. For those who doubt the variety that a purely inpatient setting can deliver, Dr. Russell eagerly quotes statistics from a two-year pilot program UCSF ran before hiring him as a full-time ENT hospitalist:

• 300 inpatient consultations the first year, not including ED and urgent care;
• Sinonasal and laryngotracheal were the most common consults;
• 200 procedures generated billings; and
• 45% of procedures were laryngotracheal, 33% were sinonasal/anterior skull base, and 10% were otologic.

"The hospitalist movement, in general, fills a need for the acute-care setting and manages a different set of problems than is seen in the ambulatory clinics,” Dr. Russell says. “That same basic issue is found in otolaryngology. I think it’s an area that is perhaps underappreciated.”

Richard Quinn is a freelance writer based in New Jersey.