Researchers say they’ve gained new insight into the production of natural killer (NK) cells.

And their findings may help them generate greater numbers of the cells in culture, which could have implications for the treatment of leukemia and other malignancies.

A previous study conducted by the same team revealed that the gene E4bp4 must be switched on to allow the immune system to produce NK cells.

Their new work suggests that E4bp4 expression is required for progenitor cells to commit to the NK lineage. And the gene promotes NK-cell development by regulating expression of the transcription factors Eomes and Id2.

The researchers described these discoveries in the Journal of Experimental Medicine.

“We are excited to find that E4bp4 has such a crucial role in determining the decisive point where blood progenitor cells become NK cells,” said study author Hugh Brady, of Imperial College London in the UK.

“We are now starting to apply this to human blood stem cells to work out how switching on E4bp4 can allow us to make lots of robust human NK cells in culture. We are hoping to make human NK cells that will have improved survival and be very toxic to cancer cells when transfused into patients. Hopefully, this will allow a big reduction in the number of NK cells needed to treat an individual patient.”

To gain insight into NK-cell production, Dr Brady and his colleagues evaluated 2 types of mice with NK-cell deficiencies. The Il15ra knockout mouse model cannot mediate IL-15 signaling, which is critical for NK-cell production. And the T-bet (Tbx21) knockout model lacks a transcription factor that’s crucial for NK-cell development.

Analysis of the Il15ra model revealed that the absence of E4bp4 perturbs NK-cell development earlier than the absence of IL-15 signaling. This suggests E4bp4 acts before IL-15, which was previously considered the definitive factor required for NK-cell production.

The researchers also found that E4bp4 is required for the production of NK progenitors, but T-bet is not. And this suggests E4bp4 acts before T-bet in NK-cell development.

To investigate these findings further, the team took cells at various stages of NK-cell differentiation from wild-type bone marrow and measured their expression of transcription factor mRNAs.

They detected E4bp4 transcript in both lymphoid-primed multipotent progenitors (LMPPs) and common lymphoid progenitors (CLPs), and E4bp4 expression increased at later stages of NK-cell development.

Based on these results, the researchers speculated that E4bp4 might be a lineage commitment factor controlling the development of NK progenitors from CLPs. To test that theory, they restored E4bp4 expression in purified E4bp4-/- CLPs to see if this could re-establish NK-cell development.

The team sorted CLPs from E4bp4-/- bone marrow, cultured them in lymphocyte-inducing conditions, transduced them with E4bp4 or empty vector, and moved on to NK-cell-inducing conditions. But neither cell type produced NK cells.

So the researchers decided to initiate the culture at an earlier developmental stage, using LMPPs. They cultured LMPPs, which exhibited a CLP phenotype at the time of transduction. And CLPs transduced with E4bp4 gave rise to NK cells, but CLPs transduced with empty vector did not.

As these results suggest that E4bp4 acts at the earliest possible point in NK-cell development, the team wanted to characterize E4bp4’s relationship with transcription factors that are likely to act downstream.

They tested several transcription factors known to play a part in NK-cell production and function. But only Eomes and Id2 proved essential for E4bp4 to direct the production of fully functional, mature NK cells.

Researchers say they’ve gained new insight into the production of natural killer (NK) cells.

And their findings may help them generate greater numbers of the cells in culture, which could have implications for the treatment of leukemia and other malignancies.

A previous study conducted by the same team revealed that the gene E4bp4 must be switched on to allow the immune system to produce NK cells.

Their new work suggests that E4bp4 expression is required for progenitor cells to commit to the NK lineage. And the gene promotes NK-cell development by regulating expression of the transcription factors Eomes and Id2.

The researchers described these discoveries in the Journal of Experimental Medicine.

“We are excited to find that E4bp4 has such a crucial role in determining the decisive point where blood progenitor cells become NK cells,” said study author Hugh Brady, of Imperial College London in the UK.

“We are now starting to apply this to human blood stem cells to work out how switching on E4bp4 can allow us to make lots of robust human NK cells in culture. We are hoping to make human NK cells that will have improved survival and be very toxic to cancer cells when transfused into patients. Hopefully, this will allow a big reduction in the number of NK cells needed to treat an individual patient.”

To gain insight into NK-cell production, Dr Brady and his colleagues evaluated 2 types of mice with NK-cell deficiencies. The Il15ra knockout mouse model cannot mediate IL-15 signaling, which is critical for NK-cell production. And the T-bet (Tbx21) knockout model lacks a transcription factor that’s crucial for NK-cell development.

Analysis of the Il15ra model revealed that the absence of E4bp4 perturbs NK-cell development earlier than the absence of IL-15 signaling. This suggests E4bp4 acts before IL-15, which was previously considered the definitive factor required for NK-cell production.

The researchers also found that E4bp4 is required for the production of NK progenitors, but T-bet is not. And this suggests E4bp4 acts before T-bet in NK-cell development.

To investigate these findings further, the team took cells at various stages of NK-cell differentiation from wild-type bone marrow and measured their expression of transcription factor mRNAs.

They detected E4bp4 transcript in both lymphoid-primed multipotent progenitors (LMPPs) and common lymphoid progenitors (CLPs), and E4bp4 expression increased at later stages of NK-cell development.

Based on these results, the researchers speculated that E4bp4 might be a lineage commitment factor controlling the development of NK progenitors from CLPs. To test that theory, they restored E4bp4 expression in purified E4bp4-/- CLPs to see if this could re-establish NK-cell development.

The team sorted CLPs from E4bp4-/- bone marrow, cultured them in lymphocyte-inducing conditions, transduced them with E4bp4 or empty vector, and moved on to NK-cell-inducing conditions. But neither cell type produced NK cells.

So the researchers decided to initiate the culture at an earlier developmental stage, using LMPPs. They cultured LMPPs, which exhibited a CLP phenotype at the time of transduction. And CLPs transduced with E4bp4 gave rise to NK cells, but CLPs transduced with empty vector did not.

As these results suggest that E4bp4 acts at the earliest possible point in NK-cell development, the team wanted to characterize E4bp4’s relationship with transcription factors that are likely to act downstream.

They tested several transcription factors known to play a part in NK-cell production and function. But only Eomes and Id2 proved essential for E4bp4 to direct the production of fully functional, mature NK cells.

Researchers say they’ve gained new insight into the production of natural killer (NK) cells.

And their findings may help them generate greater numbers of the cells in culture, which could have implications for the treatment of leukemia and other malignancies.

A previous study conducted by the same team revealed that the gene E4bp4 must be switched on to allow the immune system to produce NK cells.

Their new work suggests that E4bp4 expression is required for progenitor cells to commit to the NK lineage. And the gene promotes NK-cell development by regulating expression of the transcription factors Eomes and Id2.

The researchers described these discoveries in the Journal of Experimental Medicine.

“We are excited to find that E4bp4 has such a crucial role in determining the decisive point where blood progenitor cells become NK cells,” said study author Hugh Brady, of Imperial College London in the UK.

“We are now starting to apply this to human blood stem cells to work out how switching on E4bp4 can allow us to make lots of robust human NK cells in culture. We are hoping to make human NK cells that will have improved survival and be very toxic to cancer cells when transfused into patients. Hopefully, this will allow a big reduction in the number of NK cells needed to treat an individual patient.”

To gain insight into NK-cell production, Dr Brady and his colleagues evaluated 2 types of mice with NK-cell deficiencies. The Il15ra knockout mouse model cannot mediate IL-15 signaling, which is critical for NK-cell production. And the T-bet (Tbx21) knockout model lacks a transcription factor that’s crucial for NK-cell development.

Analysis of the Il15ra model revealed that the absence of E4bp4 perturbs NK-cell development earlier than the absence of IL-15 signaling. This suggests E4bp4 acts before IL-15, which was previously considered the definitive factor required for NK-cell production.

The researchers also found that E4bp4 is required for the production of NK progenitors, but T-bet is not. And this suggests E4bp4 acts before T-bet in NK-cell development.

To investigate these findings further, the team took cells at various stages of NK-cell differentiation from wild-type bone marrow and measured their expression of transcription factor mRNAs.

They detected E4bp4 transcript in both lymphoid-primed multipotent progenitors (LMPPs) and common lymphoid progenitors (CLPs), and E4bp4 expression increased at later stages of NK-cell development.

Based on these results, the researchers speculated that E4bp4 might be a lineage commitment factor controlling the development of NK progenitors from CLPs. To test that theory, they restored E4bp4 expression in purified E4bp4-/- CLPs to see if this could re-establish NK-cell development.

The team sorted CLPs from E4bp4-/- bone marrow, cultured them in lymphocyte-inducing conditions, transduced them with E4bp4 or empty vector, and moved on to NK-cell-inducing conditions. But neither cell type produced NK cells.

So the researchers decided to initiate the culture at an earlier developmental stage, using LMPPs. They cultured LMPPs, which exhibited a CLP phenotype at the time of transduction. And CLPs transduced with E4bp4 gave rise to NK cells, but CLPs transduced with empty vector did not.

As these results suggest that E4bp4 acts at the earliest possible point in NK-cell development, the team wanted to characterize E4bp4’s relationship with transcription factors that are likely to act downstream.

They tested several transcription factors known to play a part in NK-cell production and function. But only Eomes and Id2 proved essential for E4bp4 to direct the production of fully functional, mature NK cells.

Presenter: Lindsay Fox, MD

Summation: A dashboard is a visual representation of the key performance indicators. A dashboard can give a hospitalist team real-time feedback on desired measures. The Floating Hospital for Children Center in Boston created a network dashboard across four hospital sites. The areas measured in the pilot dashboard included descriptive quality metrics, value added activities, productivity, and group sustainability.

An example of improvement in sustainability measures was documentation of the need for more staffing by evaluating staff to RVU ratios. More staff was provided to one site that had a disproportionate ratio. An example of improvement in value added activities was hospital throughput. Discharge by 10 a.m. improved to more than 90% at several sites after implementation of this dashboard and distribution of data.

Takeaways:

• A dashboard can give a hospitalist team real time feedback on desired measures.

• A dashboard can effect change by engaging individual hospitalists.

• Dashboards are tools that are useful for several parts of the care delivery system including individual hospitalists, hospitalist programs, and for hospital administration.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

Presenter: Lindsay Fox, MD

Summation: A dashboard is a visual representation of the key performance indicators. A dashboard can give a hospitalist team real-time feedback on desired measures. The Floating Hospital for Children Center in Boston created a network dashboard across four hospital sites. The areas measured in the pilot dashboard included descriptive quality metrics, value added activities, productivity, and group sustainability.

An example of improvement in sustainability measures was documentation of the need for more staffing by evaluating staff to RVU ratios. More staff was provided to one site that had a disproportionate ratio. An example of improvement in value added activities was hospital throughput. Discharge by 10 a.m. improved to more than 90% at several sites after implementation of this dashboard and distribution of data.

Takeaways:

• A dashboard can give a hospitalist team real time feedback on desired measures.

• A dashboard can effect change by engaging individual hospitalists.

• Dashboards are tools that are useful for several parts of the care delivery system including individual hospitalists, hospitalist programs, and for hospital administration.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

Presenter: Lindsay Fox, MD

Summation: A dashboard is a visual representation of the key performance indicators. A dashboard can give a hospitalist team real-time feedback on desired measures. The Floating Hospital for Children Center in Boston created a network dashboard across four hospital sites. The areas measured in the pilot dashboard included descriptive quality metrics, value added activities, productivity, and group sustainability.

An example of improvement in sustainability measures was documentation of the need for more staffing by evaluating staff to RVU ratios. More staff was provided to one site that had a disproportionate ratio. An example of improvement in value added activities was hospital throughput. Discharge by 10 a.m. improved to more than 90% at several sites after implementation of this dashboard and distribution of data.

Takeaways:

• A dashboard can give a hospitalist team real time feedback on desired measures.

• A dashboard can effect change by engaging individual hospitalists.

• Dashboards are tools that are useful for several parts of the care delivery system including individual hospitalists, hospitalist programs, and for hospital administration.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

Presenter: Moises Auron, MD, and David Rappaport, MD

Summation: Pediatric hospitalist involvement in perioperative pediatric care covered six areas of consideration.

1) Preoperative risk. Patient-related factors, including prematurity, reflux, congenital diseases, and intercurrent illnesses increase operative risks. For many of these factors no specific remedies are available other than heightened attention to care, need, and timing of surgery.

2) Perioperative lab testing. Published data show that absent specific clinical indications there is no need for routine preop studies—including coagulation testing for T&A's. Certain circumstances: complex/prolonged surgeries or fertile females may merit limited testing.

3) Intravenous Fluids. Isotonic fluids carry lower risks of hyponatremia than hypotonic fluids.

4) VTE. VTE is the second most common hospital acquired complication. Risk factors included intubation, CVL, infection, cancer, immobility and dehydration. A graded approach to prophylaxis with more aggressive interventions for higher risk patients should be used.

5) GI stress ulcer prophylaxis. No published data are available to clearly demonstrate benefit outweighs potential risk for routine use of prophylactic antacid therapy. There is a weak recommendation for antacid prophylaxis in critically ill children. PPIs are probably equivalent to H2 blockers.

6) Pulmonary Complications. Atelectasis does not cause fever. Lots of strategies to try to prevent atelectasis—no clear data on what works. Most likely to be effective are positive pressure, either IPPV or CPAP and preoperative incentive spirometry.

Many areas of pediatric perioperative medicine lack high-quality, published data to guide care.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Moises Auron, MD, and David Rappaport, MD

Summation: Pediatric hospitalist involvement in perioperative pediatric care covered six areas of consideration.

1) Preoperative risk. Patient-related factors, including prematurity, reflux, congenital diseases, and intercurrent illnesses increase operative risks. For many of these factors no specific remedies are available other than heightened attention to care, need, and timing of surgery.

2) Perioperative lab testing. Published data show that absent specific clinical indications there is no need for routine preop studies—including coagulation testing for T&A's. Certain circumstances: complex/prolonged surgeries or fertile females may merit limited testing.

3) Intravenous Fluids. Isotonic fluids carry lower risks of hyponatremia than hypotonic fluids.

4) VTE. VTE is the second most common hospital acquired complication. Risk factors included intubation, CVL, infection, cancer, immobility and dehydration. A graded approach to prophylaxis with more aggressive interventions for higher risk patients should be used.

5) GI stress ulcer prophylaxis. No published data are available to clearly demonstrate benefit outweighs potential risk for routine use of prophylactic antacid therapy. There is a weak recommendation for antacid prophylaxis in critically ill children. PPIs are probably equivalent to H2 blockers.

6) Pulmonary Complications. Atelectasis does not cause fever. Lots of strategies to try to prevent atelectasis—no clear data on what works. Most likely to be effective are positive pressure, either IPPV or CPAP and preoperative incentive spirometry.

Many areas of pediatric perioperative medicine lack high-quality, published data to guide care.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Moises Auron, MD, and David Rappaport, MD

Summation: Pediatric hospitalist involvement in perioperative pediatric care covered six areas of consideration.

1) Preoperative risk. Patient-related factors, including prematurity, reflux, congenital diseases, and intercurrent illnesses increase operative risks. For many of these factors no specific remedies are available other than heightened attention to care, need, and timing of surgery.

2) Perioperative lab testing. Published data show that absent specific clinical indications there is no need for routine preop studies—including coagulation testing for T&A's. Certain circumstances: complex/prolonged surgeries or fertile females may merit limited testing.

3) Intravenous Fluids. Isotonic fluids carry lower risks of hyponatremia than hypotonic fluids.

4) VTE. VTE is the second most common hospital acquired complication. Risk factors included intubation, CVL, infection, cancer, immobility and dehydration. A graded approach to prophylaxis with more aggressive interventions for higher risk patients should be used.

5) GI stress ulcer prophylaxis. No published data are available to clearly demonstrate benefit outweighs potential risk for routine use of prophylactic antacid therapy. There is a weak recommendation for antacid prophylaxis in critically ill children. PPIs are probably equivalent to H2 blockers.

6) Pulmonary Complications. Atelectasis does not cause fever. Lots of strategies to try to prevent atelectasis—no clear data on what works. Most likely to be effective are positive pressure, either IPPV or CPAP and preoperative incentive spirometry.

Many areas of pediatric perioperative medicine lack high-quality, published data to guide care.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

“You have got to get it right up front,” Greg Maynard, MD, UCSD, told hospitalists at SHM's HM14 annual meeting when discussing how to leverage the electronic health record (EHR) to perform active surveillance for quality and safety deficits. “This method can be labor intensive up front, but [it] leverages the EHR and has the potential to disseminate improvement efficiently,” Dr. Maynard said. He went on to provide many specific tips and techniques for providers to use in order to design successful clinical decision support strategies.

Key Points

•  You need to be willing to redesign the system to go beyond current process measures to achieve optimal care. Currently, there can be a poor association between process measures and outcomes measures;

• You need real-time data to be able to perform a “measure-vention,” or measurement with concurrent intervention. You need to be able to collect data and then act on it for a particular patient that day;

• You need to determine who is going to act on the quality or safety deficits that are discovered once you develop measure-ventions, or real-time measures. There needs to be someone tasked with reviewing and acting on these daily reports; and

• Some institutions have developed “dynamic dashboards” that highlight active, ongoing surveillance of multiple quality improvement metrics. These help to create shared situational awareness for all providers involved in a patient’s care.

 

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

Presenters: Todd Kislak, MBA, Brian Hazen, MD, Troy Ahlstrom, MD

Summation: Two hospitalist group directors shared their scheduling tools and philosophies regarding optimal scheduling options. Dr. Hazen does the scheduling himself and Dr. Ahlstrom uses a web-based scheduling program. They both acknowledged that provider retention and satisfaction are tightly wrapped up in how you schedule providers. They recommend that groups accommodate individual preference but also be fair and equitable to the entire group.

Key Takeaways

Dr. Hazen recommended:

• Find good providers first and then try to determine their desires and fit that into the schedule as best as possible.
• Protect your nocturnists- they burn out easily and provide a key service to the hospital and your group.
• Find each person's strengths and try to cater to those to make them most successful.
• Design a weighting (or point system) for various shifts and ensure equality by using that system.
• The last day on service is a day focused on "discharges" and other patients begin with a new provider coming on service (ensures continuity and lowers LOS).

Dr. Ahlstrom recommended:

• Block schedules are hard to make flexible and do not always fit with the flux of patient loads and urgent needs of the group.
• Designing and managing the schedule is a costly endeavor and they shifted this from a physician duty to an administrator's duty. They used the Lightning Bolt solution and have enjoyed significant savings and profit.
• The ROI is made up of increased encounters, increased provider retention, and decreased locums usage.

Greg Harlan is a pediatric hospitalist, medical director for IPC The Hospitalist Company, and a member of Team Hospitalist.

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—For three hospitalists at SHM's annual meeting at the Mandalay Bay Resort and Casino, today will be a masterful day. Patrick Conway, MD, MSc, FAAP, MHM, Steven Pantilat, MD, MHM, and Jack Percelay, MD, MPH, MHM, will be designated Masters in Hospital Medicine (MHM), the growing cadre of hospitalists who have attained SHM’s highest rank. Sixteen hospitalists have attained the MHM designation. The 2014 designees will be honored on stage today during ceremonies that include the announcement of all of SHM’s new fellows and SHM’s Annual Awards of Excellence.

"If you look at the previous MHM recipients, you see the pantheon of hospital medicine—an incredible group of individuals committed to improving the healthcare system and the care of patients," Dr. Pantilat wrote in an email to The Hospitalist eWire. "This designation recognizes that there are people who have made tremendous contributions to the field, and to changing the way we care for patients."

Dr. Pantilat, who was also a member of the inaugural class of Senior Fellows in Hospital Medicine (SFHM), is a professor of medicine in the department of medicine at the University of California at San Francisco (UCSF). He’s the founding director of the UCSF Palliative Care Program and serves as director of its Leadership Center, which trains hospitalists nationwide about how to establish palliative-care services. He is also a former SHM board member and the first recipient of the SHM Excellence in Teaching Award.

"I've never been a master of anything and despite my increasing age, somehow still feel too young to be a master," Dr. Pantilat adds. "Being bestowed with this highest honor in hospital medicine definitely ranks at the top."

Dr. Conway is used to being honored, but he says he still is humbled by the designation. As a former chairman of SHM's Public Policy Committee and the current chief medical officer for the Centers for Medicare & Medicaid Services (CMS) and its deputy administrator for innovation and quality, Dr. Conway is well known—and lauded—for giving HM a voice in Washington, D.C. He views his MHM as the latest sign that his specialty continues to grow and spur positive change in health-care delivery.

"I think the designation demonstrates that hospital medicine is a maturing specialty with strong leaders," he wrote in an email. "In addition, when you look at the current and former masters…it is a stellar group of leaders who are not only advancing hospital medicine, but also changing the face of health care across our nation and improving our health system."

Dr. Percelay is so humbled that he brought his wife, daughter, and mother with him to celebrate the moment. He’s also particularly honored that he and Dr. Conway represent the field of pediatric HM, which he believes has grown tremendously in reputation over the course of his career.

"We've been able to build upon the successes of adult hospital medicine and nurture the inherent 'playing nice in the sandbox' attitude of pediatrics to grow the discipline and work force to the point it's at now where pediatric hospitalists are seen as the experts and innovators for high value pediatric inpatient care," he wrote in an email.

Dr. Percelay is a hospitalist in the pediatric ICU at Saint Barnabas Medical Center in Livingston, N.J., and teaches in the department of physician studies at Pace University of College of Health Professions in New York. He was the founding chairman for the American Academy of Pediatrics Section on Hospital Medicine, an SHM board member from 2005 to 2012, and an associate editor of the Journal of Hospital Medicine. He says attaining the rank of master ranks just behind “being my daughter's father" on his list of personal accomplishments.

 

"I've received scholarships in high school, college, and medical school, but those acknowledged at most four years of work," he writes. "This award recognizes 20-plus years of work practicing as a pediatric hospitalist in community settings, caring for children and their families, and contributing to the field as a whole."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

LAS VEGAS—Hospitalists are poised to be industry leaders and change agents as the rigmarole of healthcare reform shakes out over the next few years, a keynote speaker told a standing-room-only crowd Tuesday at HM14.

Ian Morrison, PhD, a founding partner of Strategic Health Perspectives, a forecasting service for the health-care industry that includes joint-venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management, says that while the Affordable Care Act struggled with the rollout of its health exchanges, the broader movement from fee-for-service payment structures to population-based has "turned the corner…and we ain’t going back."

"You, as a society, you, as a group, need to take the long view," Dr. Morrison told 3,500 hospitalists at the Mandalay Bay Resort and Casino. "You are going to be central to this transformation."

Morrison, a native of Scotland whose delivery is half stand-up comic, half policy wonk, says hospitalists will be on the front lines as health care shifts from local health systems to just 100 to 200 regional or super-regional systems.

And while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients' needs.

"This is the work of the future," Morrison says. "And it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future. We've got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver.

"This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at."

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

Presenter: Daniela Kroshinsky, MD, MPH

Summation: Cellulitis accounts for up to 10% of infectious disease hospitalizations and for about 3 billion/year in healthcare costs for both inpatient and outpatient treatment. Dr. Kroshinsky pointed out that dependent on patient factors, inadequately treated or recurrent cellulitis can lead to significant complications with chronic stasis changes and ulcerations. The diagnosis of cellulitis is typically made on physical exam. Cellulitis may have unusual presentations and at times the diagnosis can be difficult.

Hospitalists need to be aware that cellulitis has multiple mimics, and between 28% to 33% of patients are misdiagnosed as having cellulitis.

Dr. Kroshinsky listed a number of differential diagnoses. Frequent alternative diagnoses are dermatitis due to venous stasis or caused by lymphedema. Other skin conditions that need to be considered include erysipeloid, erythema migrans, atypical zoster, tinea and other fungal infections as well as skin changes caused by underlying malignancies.

Key Takeaways

• The diagnosis of cellulitis has a high error rate
• It is important to treat cellulitis adequately to prevent chronic skin changes and ulcers
• If cellulitis does not respond to appropriate antibacterial treatment, consider alternative diagnoses
• Be aware that many skin conditions can mimic cellulitis in immunocompromised patients

Klaus Suehler is a hospitalist at Mercy Hospital at Allina Health in Coon Rapids, Minn., and a member of Team Hospitalist.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

A Scot who describes himself as a “professional futurist,” Ian Morrison, MD, helped HM14 get off to a start with laughter. Describing the background of the changes leading to the Affordable Care Act (ACA), Dr. Morrison repeated his key point several times: “We’ve got to change the delivery system.”

This overview is very timely as the deadline for enrollment to comply with the Affordable Care Act is March 31, 2014. Dr. Morrison cited that as of March 11, more than five million Americans have enrolled in exchanges and over 80% of them have paid premiums. Up to 14 million Americans are eligible for Medicaid expansion programs. It is unknown how many of these people were previously uninsured.

Dr. Morrison described several key current issues, including:

1. There are “two Americas”—those states expanding Medicaid and those states declining any expansion;

2. The ACA is the “the Law of the Land.” The difficult task is now implementing this large change in the industry;

3. Accountable Care is a megatrend, but accountable care organizations may not continue in the form they are now;

4. Pressure on costs and delivering value is intensifying;

5. Medicare is still a major part of the healthcare system. “Learning to live in Medicare” means taking out 10% to 20% of costs; and

6. There is a renewed focus on primary care.

Dr. Morrison shared a vision of the future as these trends continue. There will continue to be “massive consolidation” in which there may be only 100-200 large regional healthcare systems in the U.S. Related to this linked care, clinical protocols will be more widely used. Care coordination of transitions will be at a premium. The transition of moving away from hospital admissions to more home care will be economically and culturally challenging.

As a transition to the future of healthcare, Dr. Morrison reviewed the concept of “the second curve” in business. Most hospitals have mastered the first curve of volume-based care, which is daily business and operations. The second curve, which is more value-based care, is a new way of doing business. Individual hospitals and healthcare systems must plan for, and succeed with, the second curve to survive. Dr. Morrison said this pressure on the healthcare system and the second curve is real, stating, “We turned the corner and we ain’t going back.”

Public purchasers will continue to play a growing role in the future. Dr. Morrison explained why Medicare Advantage is so resilient. Public employers have huge retiree health benefit problems. Dr. Morrison predicts that public payers will be more dominant by 2020 and public exchanges will grow after a rocky start.

Even with a disruptive start to the healthcare exchanges, Dr. Morrison encouraged the audience to think of the long-term benefits of the healthcare system changes.

He envisions four scenarios for the exchanges:

1. Managed competition nirvana. In this system, both public and private exchanges can grow;

2. Minor miracle. This is where the system is now at the start of exchanges;

3. Single-payer system. This would enable public exchanges to continue to grow and succeed; and

4. Meltdown, caused by patient- and system-risk or politics.

The work of the future is the transformation of the delivery system. This difficult work includes the centrality of clinical integration, information technology, “learning to live on Medicare”, managing a business model migration (from curve 1 to 2), and finally, building a culture of quality and accountability.

Dr. Morrison ended this enlightening session with several ACA implications and roles for hospitalists:

1. Take the long view. This is an area where hospitalists can continue to be leaders;

 

2. Redesign acute care, with hospitalists taking the lead;

3. Reach out beyond the walls. It will be very important for hospitalists to work even more closely with primary care providers;

4. Bring your clinical colleagues along to pursue the “triple aim” (better health, better healthcare, and lower per capita costs); and

5. Benefit patients, payers and providers through these changes.

Key points:

• “We’ve got to change the delivery system;”

• The changes in the healthcare system are areas in which hospitalists can continue to be leaders;

• ACA changes can be better for the patient, payer and provider; and

• HM14 is off to a strong start with a clear, overarching goal of hospitalists leading the changing world of medicine.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.