Editorial

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.

Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”

Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.

Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.

Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.

Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.

When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.

Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.

Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.

Documentation of gender-based disparities in medicine often focus on lower numbers of women in prominent positions as evidence of inequality and inequity; examples include lower proportion of women physicians as conference speakers,¹ first and last authors of manuscripts,² invited editorials,³ award recipients,⁴ grant recipients,⁵ medical society leadership,⁶ editorial boards,⁷ and presenters at grand rounds.⁸ Notably, these disparities are likely greater for intersectional physicians, who experience bias through multiple lenses of disadvantage.⁹ While the scarcity of women and marginalized populations in leadership roles in medicine provides convincing evidence that inequality exists, the underrepresentation of women and other marginalized physicians in prominent positions is also a cause of continued disparity. Fewer academic opportunities for women physicians and other underrepresented physician groups in medicine may perpetuate slower career advancement¹⁰ and contribute to less availability of mentors and sponsors.¹¹ Less obviously, underrepresentation also unintentionally and explicitly signals to junior faculty from marginalized groups that they are not welcome and are unlikely to be successful.^9,12

Improving representation of women in other fields has been demonstrated to reduce implicit and explicit sexism.^13,14 Increasing diversity in academic leadership is likely to further improve diversity at all levels,^9,15 which may in turn reduce gaps in health outcomes seen for marginalized patients.^16-18 Measuring and eliminating bias that disadvantages underrepresented physicians in academic opportunities is a moral imperative for institutions and organizations. For this reason, the Society of Hospital Medicine (SHM) has been attempting to address this issue within its organizational structure, publications, and conference presenters.¹⁹

The first step for an organization that aims to increase representation of women and other marginalized groups in medicine is to assess the current representation of leadership and opportunities.²⁰ If data are available, this review should include intersectional measurement of other axes of discrimination. Rapid analysis of large data sets of names is feasible using freely available computer algorithms, for example.²¹ Only once a baseline understanding of representation within an organization is established can identification of goals and areas of improvement and evaluation of efforts to increase representation begin. Reporting this data to the organization’s membership should be undertaken to increase the accountability of leadership to reduce gaps. This work is currently underway at the Journal of Hospital Medicine and within the Society of Hospital Medicine.¹⁹

This month’s issue of the Journal of Hospital Medicine includes an article written by Northcutt, et al that describes one such attempt, focusing on representation of conference speakers at SHM’s Annual Meeting. In this study, authors performed a pre- and postintervention analysis of an open call system for selecting didactic speakers for the SHM Annual Meeting. The open call system, implemented for the 2019 SHM Annual Meeting, invited all members to apply for a didactic session. The planning committee then utilized a standardized evaluation form to determine the final speaker list. In previous years, didactic speakers did not apply but were invited and were not formally evaluated. Northcutt et al report that this intervention was associated with a significant increase in the proportion of women conference speakers.²²

The Northcutt article and the open call and evaluation system is one example of an intentional adjustment to the speaker selection process aimed at recruiting more diverse presenters. Other examples of intentional efforts to increase diversity within conferences include using curated lists designed to improve representation or contacting other national organizations for recommendations. ²⁰ Efforts such as these are necessary because men in medicine are more likely to volunteer for prominent positions than women,²³ meaning that any system of recruitment or allocation of academic opportunities that relies on self-promotion is likely to perpetuate underrepresentation. Using pre-existing speakers list or previous programs will also support ongoing disparities, because men have traditionally represented the majority of speakers.

Of course, conferences are an important and public representation of a society, but are only the starting point for working towards equity within a large organization such as SHM. Similar efforts must be directed towards authorship in SHM publications, representation on editorial boards, society leadership and employment opportunities. Once organizations have an established baseline around publications, leadership recruitment, and employment representation, a review of recruitment policies (for articles, speakers, leaders, and employees) should then be conducted, looking for areas that lead to bias.

Planning committees, editorial boards, and society leadership groups should also intentionally increase their own diversity, as increasing the proportion of women on a convening committee has been demonstrated to increase the number of invited women speakers.^15,24 In addition, committees can adopt a mandate to increase diversity in invited speakers, editorials, and authorship; for example, direct instruction to avoid all-male panels led a conference planning committee to invite more women and increased the numbers of women speakers.²⁵ A speaker, authorship, or editorial policy that emphasizes diversity and inclusion should be developed and made available to the organization’s membership.²⁶

Finally, there is evidence that implicit bias training for editorial boards and conference planning committees may be effective.²⁷ Implicit bias training emphasizes that judgements of merit and skill are often subjective and based on in-group membership rather than the quality of applicants.⁹ For example, underrepresentation of women at a neuroimmunology conference was not explained by quantity or impact of previous publications,²⁸ and evaluation scores for the Society for Hospital Medicine’s Annual Meeting have increased as the proportion of women speakers has increased, suggesting that the presence of women presenters was associated with better presentations. To address concerns about how diversity and inclusion efforts may influence the quality of speakers and authors,²⁹ objective criteria could be developed in advance of a selection process and candidates should be held to the same standard.³⁰ The use of objective evaluation criteria in the selection of conference speakers has also been associated with increasing the proportion of women conference speakers. All in all, SHM’s efforts (and Northcutt’s work) should be lauded but also recognized as what they are: a good start. Continued vigilance focused on equity is the only way to ensure that the move towards greater representation continues.

Documentation of gender-based disparities in medicine often focus on lower numbers of women in prominent positions as evidence of inequality and inequity; examples include lower proportion of women physicians as conference speakers,¹ first and last authors of manuscripts,² invited editorials,³ award recipients,⁴ grant recipients,⁵ medical society leadership,⁶ editorial boards,⁷ and presenters at grand rounds.⁸ Notably, these disparities are likely greater for intersectional physicians, who experience bias through multiple lenses of disadvantage.⁹ While the scarcity of women and marginalized populations in leadership roles in medicine provides convincing evidence that inequality exists, the underrepresentation of women and other marginalized physicians in prominent positions is also a cause of continued disparity. Fewer academic opportunities for women physicians and other underrepresented physician groups in medicine may perpetuate slower career advancement¹⁰ and contribute to less availability of mentors and sponsors.¹¹ Less obviously, underrepresentation also unintentionally and explicitly signals to junior faculty from marginalized groups that they are not welcome and are unlikely to be successful.^9,12

Improving representation of women in other fields has been demonstrated to reduce implicit and explicit sexism.^13,14 Increasing diversity in academic leadership is likely to further improve diversity at all levels,^9,15 which may in turn reduce gaps in health outcomes seen for marginalized patients.^16-18 Measuring and eliminating bias that disadvantages underrepresented physicians in academic opportunities is a moral imperative for institutions and organizations. For this reason, the Society of Hospital Medicine (SHM) has been attempting to address this issue within its organizational structure, publications, and conference presenters.¹⁹

The first step for an organization that aims to increase representation of women and other marginalized groups in medicine is to assess the current representation of leadership and opportunities.²⁰ If data are available, this review should include intersectional measurement of other axes of discrimination. Rapid analysis of large data sets of names is feasible using freely available computer algorithms, for example.²¹ Only once a baseline understanding of representation within an organization is established can identification of goals and areas of improvement and evaluation of efforts to increase representation begin. Reporting this data to the organization’s membership should be undertaken to increase the accountability of leadership to reduce gaps. This work is currently underway at the Journal of Hospital Medicine and within the Society of Hospital Medicine.¹⁹

This month’s issue of the Journal of Hospital Medicine includes an article written by Northcutt, et al that describes one such attempt, focusing on representation of conference speakers at SHM’s Annual Meeting. In this study, authors performed a pre- and postintervention analysis of an open call system for selecting didactic speakers for the SHM Annual Meeting. The open call system, implemented for the 2019 SHM Annual Meeting, invited all members to apply for a didactic session. The planning committee then utilized a standardized evaluation form to determine the final speaker list. In previous years, didactic speakers did not apply but were invited and were not formally evaluated. Northcutt et al report that this intervention was associated with a significant increase in the proportion of women conference speakers.²²

The Northcutt article and the open call and evaluation system is one example of an intentional adjustment to the speaker selection process aimed at recruiting more diverse presenters. Other examples of intentional efforts to increase diversity within conferences include using curated lists designed to improve representation or contacting other national organizations for recommendations. ²⁰ Efforts such as these are necessary because men in medicine are more likely to volunteer for prominent positions than women,²³ meaning that any system of recruitment or allocation of academic opportunities that relies on self-promotion is likely to perpetuate underrepresentation. Using pre-existing speakers list or previous programs will also support ongoing disparities, because men have traditionally represented the majority of speakers.

Of course, conferences are an important and public representation of a society, but are only the starting point for working towards equity within a large organization such as SHM. Similar efforts must be directed towards authorship in SHM publications, representation on editorial boards, society leadership and employment opportunities. Once organizations have an established baseline around publications, leadership recruitment, and employment representation, a review of recruitment policies (for articles, speakers, leaders, and employees) should then be conducted, looking for areas that lead to bias.

Planning committees, editorial boards, and society leadership groups should also intentionally increase their own diversity, as increasing the proportion of women on a convening committee has been demonstrated to increase the number of invited women speakers.^15,24 In addition, committees can adopt a mandate to increase diversity in invited speakers, editorials, and authorship; for example, direct instruction to avoid all-male panels led a conference planning committee to invite more women and increased the numbers of women speakers.²⁵ A speaker, authorship, or editorial policy that emphasizes diversity and inclusion should be developed and made available to the organization’s membership.²⁶

Finally, there is evidence that implicit bias training for editorial boards and conference planning committees may be effective.²⁷ Implicit bias training emphasizes that judgements of merit and skill are often subjective and based on in-group membership rather than the quality of applicants.⁹ For example, underrepresentation of women at a neuroimmunology conference was not explained by quantity or impact of previous publications,²⁸ and evaluation scores for the Society for Hospital Medicine’s Annual Meeting have increased as the proportion of women speakers has increased, suggesting that the presence of women presenters was associated with better presentations. To address concerns about how diversity and inclusion efforts may influence the quality of speakers and authors,²⁹ objective criteria could be developed in advance of a selection process and candidates should be held to the same standard.³⁰ The use of objective evaluation criteria in the selection of conference speakers has also been associated with increasing the proportion of women conference speakers. All in all, SHM’s efforts (and Northcutt’s work) should be lauded but also recognized as what they are: a good start. Continued vigilance focused on equity is the only way to ensure that the move towards greater representation continues.

Documentation of gender-based disparities in medicine often focus on lower numbers of women in prominent positions as evidence of inequality and inequity; examples include lower proportion of women physicians as conference speakers,¹ first and last authors of manuscripts,² invited editorials,³ award recipients,⁴ grant recipients,⁵ medical society leadership,⁶ editorial boards,⁷ and presenters at grand rounds.⁸ Notably, these disparities are likely greater for intersectional physicians, who experience bias through multiple lenses of disadvantage.⁹ While the scarcity of women and marginalized populations in leadership roles in medicine provides convincing evidence that inequality exists, the underrepresentation of women and other marginalized physicians in prominent positions is also a cause of continued disparity. Fewer academic opportunities for women physicians and other underrepresented physician groups in medicine may perpetuate slower career advancement¹⁰ and contribute to less availability of mentors and sponsors.¹¹ Less obviously, underrepresentation also unintentionally and explicitly signals to junior faculty from marginalized groups that they are not welcome and are unlikely to be successful.^9,12

Improving representation of women in other fields has been demonstrated to reduce implicit and explicit sexism.^13,14 Increasing diversity in academic leadership is likely to further improve diversity at all levels,^9,15 which may in turn reduce gaps in health outcomes seen for marginalized patients.^16-18 Measuring and eliminating bias that disadvantages underrepresented physicians in academic opportunities is a moral imperative for institutions and organizations. For this reason, the Society of Hospital Medicine (SHM) has been attempting to address this issue within its organizational structure, publications, and conference presenters.¹⁹

The first step for an organization that aims to increase representation of women and other marginalized groups in medicine is to assess the current representation of leadership and opportunities.²⁰ If data are available, this review should include intersectional measurement of other axes of discrimination. Rapid analysis of large data sets of names is feasible using freely available computer algorithms, for example.²¹ Only once a baseline understanding of representation within an organization is established can identification of goals and areas of improvement and evaluation of efforts to increase representation begin. Reporting this data to the organization’s membership should be undertaken to increase the accountability of leadership to reduce gaps. This work is currently underway at the Journal of Hospital Medicine and within the Society of Hospital Medicine.¹⁹

This month’s issue of the Journal of Hospital Medicine includes an article written by Northcutt, et al that describes one such attempt, focusing on representation of conference speakers at SHM’s Annual Meeting. In this study, authors performed a pre- and postintervention analysis of an open call system for selecting didactic speakers for the SHM Annual Meeting. The open call system, implemented for the 2019 SHM Annual Meeting, invited all members to apply for a didactic session. The planning committee then utilized a standardized evaluation form to determine the final speaker list. In previous years, didactic speakers did not apply but were invited and were not formally evaluated. Northcutt et al report that this intervention was associated with a significant increase in the proportion of women conference speakers.²²

The Northcutt article and the open call and evaluation system is one example of an intentional adjustment to the speaker selection process aimed at recruiting more diverse presenters. Other examples of intentional efforts to increase diversity within conferences include using curated lists designed to improve representation or contacting other national organizations for recommendations. ²⁰ Efforts such as these are necessary because men in medicine are more likely to volunteer for prominent positions than women,²³ meaning that any system of recruitment or allocation of academic opportunities that relies on self-promotion is likely to perpetuate underrepresentation. Using pre-existing speakers list or previous programs will also support ongoing disparities, because men have traditionally represented the majority of speakers.

Of course, conferences are an important and public representation of a society, but are only the starting point for working towards equity within a large organization such as SHM. Similar efforts must be directed towards authorship in SHM publications, representation on editorial boards, society leadership and employment opportunities. Once organizations have an established baseline around publications, leadership recruitment, and employment representation, a review of recruitment policies (for articles, speakers, leaders, and employees) should then be conducted, looking for areas that lead to bias.

Planning committees, editorial boards, and society leadership groups should also intentionally increase their own diversity, as increasing the proportion of women on a convening committee has been demonstrated to increase the number of invited women speakers.^15,24 In addition, committees can adopt a mandate to increase diversity in invited speakers, editorials, and authorship; for example, direct instruction to avoid all-male panels led a conference planning committee to invite more women and increased the numbers of women speakers.²⁵ A speaker, authorship, or editorial policy that emphasizes diversity and inclusion should be developed and made available to the organization’s membership.²⁶

Finally, there is evidence that implicit bias training for editorial boards and conference planning committees may be effective.²⁷ Implicit bias training emphasizes that judgements of merit and skill are often subjective and based on in-group membership rather than the quality of applicants.⁹ For example, underrepresentation of women at a neuroimmunology conference was not explained by quantity or impact of previous publications,²⁸ and evaluation scores for the Society for Hospital Medicine’s Annual Meeting have increased as the proportion of women speakers has increased, suggesting that the presence of women presenters was associated with better presentations. To address concerns about how diversity and inclusion efforts may influence the quality of speakers and authors,²⁹ objective criteria could be developed in advance of a selection process and candidates should be held to the same standard.³⁰ The use of objective evaluation criteria in the selection of conference speakers has also been associated with increasing the proportion of women conference speakers. All in all, SHM’s efforts (and Northcutt’s work) should be lauded but also recognized as what they are: a good start. Continued vigilance focused on equity is the only way to ensure that the move towards greater representation continues.

The enthusiasm surrounding point-of-care ultrasound (POCUS) is clear and well founded. POCUS is a powerful tool that produces valuable diagnostic information for common and important clinical problems faced by hospitalists, such as pneumonia, soft-tissue infections,¹ and myriad other applications. It can inform the evaluation and management of complex clinical problems such as dyspnea.² Beyond its diagnostic potential, POCUS is well known to improve common procedures performed by adult and pediatric hospitalists by improving success rates and decreasing complications.

Excitement surrounding this technology continues to grow among hospitalists, leading to a proliferation of high-quality educational programs over the last 5 years. Most notable among these offerings has been the more comprehensive training available through the Society of Hospital Medicine (SHM) certificate-based pathway, though many other strong options exist, including institution-based curricula, such as the HealthPartners CHAMP program,³ and pediatric-focused programs. Growth in training is also occurring among medical students and residents. As of a 2012 survey, the majority (51%) of US medical schools had begun to weave ultrasound into their curricula,⁴ and this growth is also occurring in internal medicine and pediatric residency programs.⁵

Given the high potential for this technology and the growth in interest, it is an excellent time to pause and review some of the challenges faced by practitioners, hospitalist groups, and educators seeking to optimize POCUS implementation. A deliberate approach to POCUS education, the development of shared standards for high-quality use, and an ongoing dedication to develop specialty-specific practices will largely determine how much of this potential is fulfilled.

The largest challenge is likely to be educational. Educating clinicians to be able to integrate POCUS into practice is a complex, multistep process requiring not only an adequate core of didactic training and access to machines, but also the structured opportunity to develop rudimentary hands-on skills. Such initial training should be followed by continued practice and feedback as developing POCUS users progress toward independent practice. The study by Kumar et al.⁶ reaffirms that brief didactic lectures and access to machines are necessary, but they are clearly insufficient for learners to be able to use POCUS independently for a wide variety of applications. Their intervention also contrasts markedly with the 20 hours of didactics and 150 supervised scans recommended by the American College of Emergency Physicians prior to independent use for a core of six applications.⁷

Shared standards for education, use, and oversight will be crucial to fulfilling the potential of POCUS within hospital medicine. Our belief is that much can be learned from the thoughtful approach taken during the development of POCUS as a mainstream tool in emergency medicine in the early 2000s. In this approach, emergency physicians determined a sufficient and achievable standard of training for core POCUS applications, which was widely adopted. Based on completion of this training, physicians who were required to complete credentialing from their hospitals were widely able to achieve it, without any need for external certification. Emergency medicine guidelines further mandated the documentation of examinations and the creation of an exam report, features that improve clinical communication and facilitate quality improvement. Quality assurance processes that reviewed images and clinician interpretations were established as mandatory, which they should be in hospital medicine. Evidence was produced as to which exams physicians could do reliably with this focused training and which they could not. In the context of these thoughtful constructs, lawsuits have been noted to be exceedingly rare; and when they do occur, they have typically been for the failure to use POCUS rather than the converse.⁸

While many of these precepts deserve replication, others should also be modified to reflect changes in technology, medical education, and medical practice over the last 20 years and to improve upon this base of success. For example, with POCUS training now appearing in many medical school and residency curricula, training paradigms for both residents and attendings will need to accommodate a wider range of incoming skills. Emphasis should continue to be shifted toward competency-based assessments and entrustment and away from a fixed training time or exam number threshold. Important financial aspects have also changed. The cost of practical machines has dropped considerably, and medicine is shifting away from a fee-for-service model. While it remains appropriate that physicians may bill for POCUS examinations, it is likely that improved diagnosis, improved throughput, and a reduction in complications will yield greater value and should be the emphasis of cost/value discussions.⁹ Finally, while hospitals may impose credentialing, this process can also create a burden not present for most other noninvasive skills and may deter appropriate use. If this approach is chosen by a hospital, requirements should ideally remain modest, and as these skills become more widespread, POCUS should ultimately be built into board examinations and core credentialing.⁹

Thoughtful and concerted effort will be required by hospitalist leaders, educational innovators, and professional societies in developing POCUS to best serve hospitalists and their patients. This work has already begun. For example, in 2019 SHM offered a position statement outlining important aspects such as current evidence-based applications, training pathways, quality assurance, and program management.¹⁰ These recommendations should guide both adult and pediatric hospitalists. The Alliance for Academic Internal Medicine offered a similar position statement for resident training.¹¹ Interest groups are growing in numerous professional societies, which will facilitate collaboration and promote propagation of best practices. High-quality educational tools are continuing to be developed by numerous organizations.

While further development is needed to add the detail, granularity, and practical tools that educational and practice leaders need to assure that POCUS achieves its potential in hospital medicine, the foundation for POCUS use within the specialty is being thoughtfully constructed. As this process proceeds, it will be vital to continue to learn from our emergency medicine colleagues, who have already met similar challenges, while at the same time be able to develop a modern POCUS model optimized for hospital medicine workflow, training, and patient care.

The enthusiasm surrounding point-of-care ultrasound (POCUS) is clear and well founded. POCUS is a powerful tool that produces valuable diagnostic information for common and important clinical problems faced by hospitalists, such as pneumonia, soft-tissue infections,¹ and myriad other applications. It can inform the evaluation and management of complex clinical problems such as dyspnea.² Beyond its diagnostic potential, POCUS is well known to improve common procedures performed by adult and pediatric hospitalists by improving success rates and decreasing complications.

Excitement surrounding this technology continues to grow among hospitalists, leading to a proliferation of high-quality educational programs over the last 5 years. Most notable among these offerings has been the more comprehensive training available through the Society of Hospital Medicine (SHM) certificate-based pathway, though many other strong options exist, including institution-based curricula, such as the HealthPartners CHAMP program,³ and pediatric-focused programs. Growth in training is also occurring among medical students and residents. As of a 2012 survey, the majority (51%) of US medical schools had begun to weave ultrasound into their curricula,⁴ and this growth is also occurring in internal medicine and pediatric residency programs.⁵

Given the high potential for this technology and the growth in interest, it is an excellent time to pause and review some of the challenges faced by practitioners, hospitalist groups, and educators seeking to optimize POCUS implementation. A deliberate approach to POCUS education, the development of shared standards for high-quality use, and an ongoing dedication to develop specialty-specific practices will largely determine how much of this potential is fulfilled.

The largest challenge is likely to be educational. Educating clinicians to be able to integrate POCUS into practice is a complex, multistep process requiring not only an adequate core of didactic training and access to machines, but also the structured opportunity to develop rudimentary hands-on skills. Such initial training should be followed by continued practice and feedback as developing POCUS users progress toward independent practice. The study by Kumar et al.⁶ reaffirms that brief didactic lectures and access to machines are necessary, but they are clearly insufficient for learners to be able to use POCUS independently for a wide variety of applications. Their intervention also contrasts markedly with the 20 hours of didactics and 150 supervised scans recommended by the American College of Emergency Physicians prior to independent use for a core of six applications.⁷

Shared standards for education, use, and oversight will be crucial to fulfilling the potential of POCUS within hospital medicine. Our belief is that much can be learned from the thoughtful approach taken during the development of POCUS as a mainstream tool in emergency medicine in the early 2000s. In this approach, emergency physicians determined a sufficient and achievable standard of training for core POCUS applications, which was widely adopted. Based on completion of this training, physicians who were required to complete credentialing from their hospitals were widely able to achieve it, without any need for external certification. Emergency medicine guidelines further mandated the documentation of examinations and the creation of an exam report, features that improve clinical communication and facilitate quality improvement. Quality assurance processes that reviewed images and clinician interpretations were established as mandatory, which they should be in hospital medicine. Evidence was produced as to which exams physicians could do reliably with this focused training and which they could not. In the context of these thoughtful constructs, lawsuits have been noted to be exceedingly rare; and when they do occur, they have typically been for the failure to use POCUS rather than the converse.⁸

While many of these precepts deserve replication, others should also be modified to reflect changes in technology, medical education, and medical practice over the last 20 years and to improve upon this base of success. For example, with POCUS training now appearing in many medical school and residency curricula, training paradigms for both residents and attendings will need to accommodate a wider range of incoming skills. Emphasis should continue to be shifted toward competency-based assessments and entrustment and away from a fixed training time or exam number threshold. Important financial aspects have also changed. The cost of practical machines has dropped considerably, and medicine is shifting away from a fee-for-service model. While it remains appropriate that physicians may bill for POCUS examinations, it is likely that improved diagnosis, improved throughput, and a reduction in complications will yield greater value and should be the emphasis of cost/value discussions.⁹ Finally, while hospitals may impose credentialing, this process can also create a burden not present for most other noninvasive skills and may deter appropriate use. If this approach is chosen by a hospital, requirements should ideally remain modest, and as these skills become more widespread, POCUS should ultimately be built into board examinations and core credentialing.⁹

Thoughtful and concerted effort will be required by hospitalist leaders, educational innovators, and professional societies in developing POCUS to best serve hospitalists and their patients. This work has already begun. For example, in 2019 SHM offered a position statement outlining important aspects such as current evidence-based applications, training pathways, quality assurance, and program management.¹⁰ These recommendations should guide both adult and pediatric hospitalists. The Alliance for Academic Internal Medicine offered a similar position statement for resident training.¹¹ Interest groups are growing in numerous professional societies, which will facilitate collaboration and promote propagation of best practices. High-quality educational tools are continuing to be developed by numerous organizations.

While further development is needed to add the detail, granularity, and practical tools that educational and practice leaders need to assure that POCUS achieves its potential in hospital medicine, the foundation for POCUS use within the specialty is being thoughtfully constructed. As this process proceeds, it will be vital to continue to learn from our emergency medicine colleagues, who have already met similar challenges, while at the same time be able to develop a modern POCUS model optimized for hospital medicine workflow, training, and patient care.

The enthusiasm surrounding point-of-care ultrasound (POCUS) is clear and well founded. POCUS is a powerful tool that produces valuable diagnostic information for common and important clinical problems faced by hospitalists, such as pneumonia, soft-tissue infections,¹ and myriad other applications. It can inform the evaluation and management of complex clinical problems such as dyspnea.² Beyond its diagnostic potential, POCUS is well known to improve common procedures performed by adult and pediatric hospitalists by improving success rates and decreasing complications.

Excitement surrounding this technology continues to grow among hospitalists, leading to a proliferation of high-quality educational programs over the last 5 years. Most notable among these offerings has been the more comprehensive training available through the Society of Hospital Medicine (SHM) certificate-based pathway, though many other strong options exist, including institution-based curricula, such as the HealthPartners CHAMP program,³ and pediatric-focused programs. Growth in training is also occurring among medical students and residents. As of a 2012 survey, the majority (51%) of US medical schools had begun to weave ultrasound into their curricula,⁴ and this growth is also occurring in internal medicine and pediatric residency programs.⁵

Given the high potential for this technology and the growth in interest, it is an excellent time to pause and review some of the challenges faced by practitioners, hospitalist groups, and educators seeking to optimize POCUS implementation. A deliberate approach to POCUS education, the development of shared standards for high-quality use, and an ongoing dedication to develop specialty-specific practices will largely determine how much of this potential is fulfilled.

The largest challenge is likely to be educational. Educating clinicians to be able to integrate POCUS into practice is a complex, multistep process requiring not only an adequate core of didactic training and access to machines, but also the structured opportunity to develop rudimentary hands-on skills. Such initial training should be followed by continued practice and feedback as developing POCUS users progress toward independent practice. The study by Kumar et al.⁶ reaffirms that brief didactic lectures and access to machines are necessary, but they are clearly insufficient for learners to be able to use POCUS independently for a wide variety of applications. Their intervention also contrasts markedly with the 20 hours of didactics and 150 supervised scans recommended by the American College of Emergency Physicians prior to independent use for a core of six applications.⁷

Shared standards for education, use, and oversight will be crucial to fulfilling the potential of POCUS within hospital medicine. Our belief is that much can be learned from the thoughtful approach taken during the development of POCUS as a mainstream tool in emergency medicine in the early 2000s. In this approach, emergency physicians determined a sufficient and achievable standard of training for core POCUS applications, which was widely adopted. Based on completion of this training, physicians who were required to complete credentialing from their hospitals were widely able to achieve it, without any need for external certification. Emergency medicine guidelines further mandated the documentation of examinations and the creation of an exam report, features that improve clinical communication and facilitate quality improvement. Quality assurance processes that reviewed images and clinician interpretations were established as mandatory, which they should be in hospital medicine. Evidence was produced as to which exams physicians could do reliably with this focused training and which they could not. In the context of these thoughtful constructs, lawsuits have been noted to be exceedingly rare; and when they do occur, they have typically been for the failure to use POCUS rather than the converse.⁸

While many of these precepts deserve replication, others should also be modified to reflect changes in technology, medical education, and medical practice over the last 20 years and to improve upon this base of success. For example, with POCUS training now appearing in many medical school and residency curricula, training paradigms for both residents and attendings will need to accommodate a wider range of incoming skills. Emphasis should continue to be shifted toward competency-based assessments and entrustment and away from a fixed training time or exam number threshold. Important financial aspects have also changed. The cost of practical machines has dropped considerably, and medicine is shifting away from a fee-for-service model. While it remains appropriate that physicians may bill for POCUS examinations, it is likely that improved diagnosis, improved throughput, and a reduction in complications will yield greater value and should be the emphasis of cost/value discussions.⁹ Finally, while hospitals may impose credentialing, this process can also create a burden not present for most other noninvasive skills and may deter appropriate use. If this approach is chosen by a hospital, requirements should ideally remain modest, and as these skills become more widespread, POCUS should ultimately be built into board examinations and core credentialing.⁹

Thoughtful and concerted effort will be required by hospitalist leaders, educational innovators, and professional societies in developing POCUS to best serve hospitalists and their patients. This work has already begun. For example, in 2019 SHM offered a position statement outlining important aspects such as current evidence-based applications, training pathways, quality assurance, and program management.¹⁰ These recommendations should guide both adult and pediatric hospitalists. The Alliance for Academic Internal Medicine offered a similar position statement for resident training.¹¹ Interest groups are growing in numerous professional societies, which will facilitate collaboration and promote propagation of best practices. High-quality educational tools are continuing to be developed by numerous organizations.

While further development is needed to add the detail, granularity, and practical tools that educational and practice leaders need to assure that POCUS achieves its potential in hospital medicine, the foundation for POCUS use within the specialty is being thoughtfully constructed. As this process proceeds, it will be vital to continue to learn from our emergency medicine colleagues, who have already met similar challenges, while at the same time be able to develop a modern POCUS model optimized for hospital medicine workflow, training, and patient care.

What childhood game better captures communication exchange than “telephone”: as whispers pass from ear to ear, the original message degrades or transforms entirely. In complex healthcare systems, a more perilous version of “telephone” emerges, distinct from the well-worn metaphor: the signal never arrives at all. The primary care provider never even knew the patient was in the hospital; the discharge summary was never received; the patient cannot remember important details; and key medications are missing. In this edition of the Journal, Roman Ayele et al.¹ used qualitative methods to explore this transitional black box between community hospitals and Veterans’ Affairs (VA) primary care clinics, illuminating how signal fragmentation may render the increasing use of care services outside the VA system as inversely proportionate to quality.

To understand why, a small amount of historical context is necessary. The VA has increasingly focused on expanding healthcare options to its nine million veterans. On June 6, 2019, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was passed to consolidate existing programs and lower barriers for Veterans to seek care in non-VA urgent care and subspecialty settings.² Though this act is not specifically focused on access to community hospitals, patients seeking urgent and subspecialty care are likely to be increasingly hospitalized outside of the VA due to geographic factors affecting point-of-care decisions. Concurrent with this expansion of options is the planned replacement of the VA’s legacy electronic health record, VistA.³ Both transformations indicate the need for the VA to be watchful and to intensify its focus on safe, effective exchanges of information.

Against this backdrop, Ayele et al.³ use stakeholder interviews with veterans and both non-VA and VA clinicians to identify the current lack of standardized practices for transitions of veteran care from community hospitals to VA primary care in Eastern Colorado. The themes most linked to care fragmentation included difficulty in identifying veterans and notifying VA primary care of hospital discharges, transferring medical records, making follow-up appointments, and coordinating prescribing with VA pharmacies. Participants identified incomplete or delayed information exchanges that were further complicated by the inability to confirm transmission across systems. A patchwork of postacute care solutions failed to prevent wasteful, low-value transitional care, including unscheduled primary care walk-ins and ED visits for medication refills. Participants arrived at a simple common solution: develop a clinically trained “VA liaison” to work at the interface between VA primary care and non-VA community hospitals so as to provide a single point of contact to coordinate these transitions. In short, to have someone to pick up the phone.

The strengths of this qualitative study lie in its insights into the current gaps in care transitions through the eyes of key stakeholders. By engaging patients and providers in imagining system changes that are actionable in the near- (clinical VA liaisons) and longer-term (pharmacy and EHR integration), Ayele et al. have provided a helpful starting place in studying and improving the interface between VA and non-VA care. Stakeholders emphasized the importance of a clear access point so that outside providers can easily notify VA clinics, arrange follow-ups, and streamline physician prescribing to avoid dangerous and costly delays in care.⁴ Though similar issues have been illuminated in prior work on care fragmentation,⁴ perspective in context is a fundamental strength of qualitative research, and further highlights the urgency of this period in veteran care.

There is the old adage: “if you have seen one VA, you have seen one VA”. This is arguably reflected in how each VA medical center is situated in a different regional and local healthcare delivery context, despite a common national infrastructure. The authors acknowledge limited generalizability but provide a framework for reproducing such work in regional VA systems. A national model for transitioning patients from regional community partners to VA primary care would require further testing, and to be a credible system-wide investment, would necessitate meaningful measurement across multiple sites. Given recent evidence of strong internal VA performance compared to the private sector,⁵ it is time for the VA to intensify focus on external care transitions. Given its history and continued commitment to funding innovation,⁶ the VA ought to be up to the task. Yet, as VA hospitalists, we know only too well that the system is increasingly under pressure to apply constrained resources inside and outside its own walls. Sending business elsewhere might not only fail at improving care but also weaken the fragile care delivery infrastructure.⁷

The idea that access and continuity may be in conflict raises an ethical question in modern practice and shared decision-making: how do we advise patients navigating complicated and imperfect health systems to understand the choices they are making and the risks they are taking when they spread care across systems? How are access and convenience weighed against the troubled movement of information across systems? How great is the risk if their care teams do not hear the same message? Knowing that increased fragmentation disproportionately affects the marginalized and vulnerable, especially those with complex chronic care needs,⁸ should we advise certain patients to stay in place within a single system?

As hospitalists, we are implied players in this dangerous version of the telephone game at a fascinating time in healthcare. Unlike when we advise patients on the risks and benefits of treatment, we have little evidence to guide our patients on when to stay put and when to leave to get care outside the system, inviting the risk of lost signals, garbled messages, and worst of all, frustrating, duplicative, unsafe care. As we strive for incremental improvements toward sweeping transformations in healthcare, we may for a few more years have to remind each other—and our students—of the incredible value of one more phone call: to make sure the intended message was received.

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

What childhood game better captures communication exchange than “telephone”: as whispers pass from ear to ear, the original message degrades or transforms entirely. In complex healthcare systems, a more perilous version of “telephone” emerges, distinct from the well-worn metaphor: the signal never arrives at all. The primary care provider never even knew the patient was in the hospital; the discharge summary was never received; the patient cannot remember important details; and key medications are missing. In this edition of the Journal, Roman Ayele et al.¹ used qualitative methods to explore this transitional black box between community hospitals and Veterans’ Affairs (VA) primary care clinics, illuminating how signal fragmentation may render the increasing use of care services outside the VA system as inversely proportionate to quality.

To understand why, a small amount of historical context is necessary. The VA has increasingly focused on expanding healthcare options to its nine million veterans. On June 6, 2019, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was passed to consolidate existing programs and lower barriers for Veterans to seek care in non-VA urgent care and subspecialty settings.² Though this act is not specifically focused on access to community hospitals, patients seeking urgent and subspecialty care are likely to be increasingly hospitalized outside of the VA due to geographic factors affecting point-of-care decisions. Concurrent with this expansion of options is the planned replacement of the VA’s legacy electronic health record, VistA.³ Both transformations indicate the need for the VA to be watchful and to intensify its focus on safe, effective exchanges of information.

Against this backdrop, Ayele et al.³ use stakeholder interviews with veterans and both non-VA and VA clinicians to identify the current lack of standardized practices for transitions of veteran care from community hospitals to VA primary care in Eastern Colorado. The themes most linked to care fragmentation included difficulty in identifying veterans and notifying VA primary care of hospital discharges, transferring medical records, making follow-up appointments, and coordinating prescribing with VA pharmacies. Participants identified incomplete or delayed information exchanges that were further complicated by the inability to confirm transmission across systems. A patchwork of postacute care solutions failed to prevent wasteful, low-value transitional care, including unscheduled primary care walk-ins and ED visits for medication refills. Participants arrived at a simple common solution: develop a clinically trained “VA liaison” to work at the interface between VA primary care and non-VA community hospitals so as to provide a single point of contact to coordinate these transitions. In short, to have someone to pick up the phone.

The strengths of this qualitative study lie in its insights into the current gaps in care transitions through the eyes of key stakeholders. By engaging patients and providers in imagining system changes that are actionable in the near- (clinical VA liaisons) and longer-term (pharmacy and EHR integration), Ayele et al. have provided a helpful starting place in studying and improving the interface between VA and non-VA care. Stakeholders emphasized the importance of a clear access point so that outside providers can easily notify VA clinics, arrange follow-ups, and streamline physician prescribing to avoid dangerous and costly delays in care.⁴ Though similar issues have been illuminated in prior work on care fragmentation,⁴ perspective in context is a fundamental strength of qualitative research, and further highlights the urgency of this period in veteran care.

There is the old adage: “if you have seen one VA, you have seen one VA”. This is arguably reflected in how each VA medical center is situated in a different regional and local healthcare delivery context, despite a common national infrastructure. The authors acknowledge limited generalizability but provide a framework for reproducing such work in regional VA systems. A national model for transitioning patients from regional community partners to VA primary care would require further testing, and to be a credible system-wide investment, would necessitate meaningful measurement across multiple sites. Given recent evidence of strong internal VA performance compared to the private sector,⁵ it is time for the VA to intensify focus on external care transitions. Given its history and continued commitment to funding innovation,⁶ the VA ought to be up to the task. Yet, as VA hospitalists, we know only too well that the system is increasingly under pressure to apply constrained resources inside and outside its own walls. Sending business elsewhere might not only fail at improving care but also weaken the fragile care delivery infrastructure.⁷

The idea that access and continuity may be in conflict raises an ethical question in modern practice and shared decision-making: how do we advise patients navigating complicated and imperfect health systems to understand the choices they are making and the risks they are taking when they spread care across systems? How are access and convenience weighed against the troubled movement of information across systems? How great is the risk if their care teams do not hear the same message? Knowing that increased fragmentation disproportionately affects the marginalized and vulnerable, especially those with complex chronic care needs,⁸ should we advise certain patients to stay in place within a single system?

As hospitalists, we are implied players in this dangerous version of the telephone game at a fascinating time in healthcare. Unlike when we advise patients on the risks and benefits of treatment, we have little evidence to guide our patients on when to stay put and when to leave to get care outside the system, inviting the risk of lost signals, garbled messages, and worst of all, frustrating, duplicative, unsafe care. As we strive for incremental improvements toward sweeping transformations in healthcare, we may for a few more years have to remind each other—and our students—of the incredible value of one more phone call: to make sure the intended message was received.

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

What childhood game better captures communication exchange than “telephone”: as whispers pass from ear to ear, the original message degrades or transforms entirely. In complex healthcare systems, a more perilous version of “telephone” emerges, distinct from the well-worn metaphor: the signal never arrives at all. The primary care provider never even knew the patient was in the hospital; the discharge summary was never received; the patient cannot remember important details; and key medications are missing. In this edition of the Journal, Roman Ayele et al.¹ used qualitative methods to explore this transitional black box between community hospitals and Veterans’ Affairs (VA) primary care clinics, illuminating how signal fragmentation may render the increasing use of care services outside the VA system as inversely proportionate to quality.

To understand why, a small amount of historical context is necessary. The VA has increasingly focused on expanding healthcare options to its nine million veterans. On June 6, 2019, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was passed to consolidate existing programs and lower barriers for Veterans to seek care in non-VA urgent care and subspecialty settings.² Though this act is not specifically focused on access to community hospitals, patients seeking urgent and subspecialty care are likely to be increasingly hospitalized outside of the VA due to geographic factors affecting point-of-care decisions. Concurrent with this expansion of options is the planned replacement of the VA’s legacy electronic health record, VistA.³ Both transformations indicate the need for the VA to be watchful and to intensify its focus on safe, effective exchanges of information.

Against this backdrop, Ayele et al.³ use stakeholder interviews with veterans and both non-VA and VA clinicians to identify the current lack of standardized practices for transitions of veteran care from community hospitals to VA primary care in Eastern Colorado. The themes most linked to care fragmentation included difficulty in identifying veterans and notifying VA primary care of hospital discharges, transferring medical records, making follow-up appointments, and coordinating prescribing with VA pharmacies. Participants identified incomplete or delayed information exchanges that were further complicated by the inability to confirm transmission across systems. A patchwork of postacute care solutions failed to prevent wasteful, low-value transitional care, including unscheduled primary care walk-ins and ED visits for medication refills. Participants arrived at a simple common solution: develop a clinically trained “VA liaison” to work at the interface between VA primary care and non-VA community hospitals so as to provide a single point of contact to coordinate these transitions. In short, to have someone to pick up the phone.

The strengths of this qualitative study lie in its insights into the current gaps in care transitions through the eyes of key stakeholders. By engaging patients and providers in imagining system changes that are actionable in the near- (clinical VA liaisons) and longer-term (pharmacy and EHR integration), Ayele et al. have provided a helpful starting place in studying and improving the interface between VA and non-VA care. Stakeholders emphasized the importance of a clear access point so that outside providers can easily notify VA clinics, arrange follow-ups, and streamline physician prescribing to avoid dangerous and costly delays in care.⁴ Though similar issues have been illuminated in prior work on care fragmentation,⁴ perspective in context is a fundamental strength of qualitative research, and further highlights the urgency of this period in veteran care.

There is the old adage: “if you have seen one VA, you have seen one VA”. This is arguably reflected in how each VA medical center is situated in a different regional and local healthcare delivery context, despite a common national infrastructure. The authors acknowledge limited generalizability but provide a framework for reproducing such work in regional VA systems. A national model for transitioning patients from regional community partners to VA primary care would require further testing, and to be a credible system-wide investment, would necessitate meaningful measurement across multiple sites. Given recent evidence of strong internal VA performance compared to the private sector,⁵ it is time for the VA to intensify focus on external care transitions. Given its history and continued commitment to funding innovation,⁶ the VA ought to be up to the task. Yet, as VA hospitalists, we know only too well that the system is increasingly under pressure to apply constrained resources inside and outside its own walls. Sending business elsewhere might not only fail at improving care but also weaken the fragile care delivery infrastructure.⁷

The idea that access and continuity may be in conflict raises an ethical question in modern practice and shared decision-making: how do we advise patients navigating complicated and imperfect health systems to understand the choices they are making and the risks they are taking when they spread care across systems? How are access and convenience weighed against the troubled movement of information across systems? How great is the risk if their care teams do not hear the same message? Knowing that increased fragmentation disproportionately affects the marginalized and vulnerable, especially those with complex chronic care needs,⁸ should we advise certain patients to stay in place within a single system?

As hospitalists, we are implied players in this dangerous version of the telephone game at a fascinating time in healthcare. Unlike when we advise patients on the risks and benefits of treatment, we have little evidence to guide our patients on when to stay put and when to leave to get care outside the system, inviting the risk of lost signals, garbled messages, and worst of all, frustrating, duplicative, unsafe care. As we strive for incremental improvements toward sweeping transformations in healthcare, we may for a few more years have to remind each other—and our students—of the incredible value of one more phone call: to make sure the intended message was received.

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.

The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,¹ the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.

This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.² Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.³ In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.⁴

Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.

Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.

Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer⁵ and site-specific⁶ datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.

The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.

As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.⁷ The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.⁸ Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.

Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.

Acknowledgments

The authors thank Mary Akel for her assistance with manuscript submission.

Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.

The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,¹ the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.

This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.² Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.³ In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.⁴

Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.

Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.

Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer⁵ and site-specific⁶ datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.

The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.

As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.⁷ The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.⁸ Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.

Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.

Acknowledgments

The authors thank Mary Akel for her assistance with manuscript submission.

Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.

The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,¹ the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.

This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.² Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.³ In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.⁴

Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.

Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.

Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer⁵ and site-specific⁶ datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.

The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.

As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.⁷ The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.⁸ Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.

Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.

Acknowledgments

The authors thank Mary Akel for her assistance with manuscript submission.