Practice Management

A collaboration between hospitalists and the pain department at Beth Israel Medical Center in New York City is helping hospitalists address moderate to severe pain and complicating factors in their patients.

“The idea was to impart knowledge from a small group of experts to the hospitalists who manage pain in the majority of hospitalized patients,” says Dahlia Rizk, DO, chief of hospital medicine at Beth Israel and lead author on a poster that described the program and was presented at HM13 in Washington, D.C.¹

Dr. Rizk first approached Russell Portenoy, MD, internationally recognized chair of the Department of Pain Management and Palliative Care at Beth Israel, to draw upon his specialized knowledge. Grant funding supported protected time for two hospitalist champions and a nurse practitioner; they reviewed charts on participating units and conducted focus groups with hospitalists to identify barriers to effective pain management. Barriers were compiled into a 56-item menu and shaped the curriculum for weekly training sessions presented by the pain service.

Dr. Portenoy and the project team also established a metric for “high sustained pain,” patients reporting three or more days of three or more episodes of moderate to severe pain, according to the hospital’s standardized pain assessment scale. The information was captured in a computerized, tablet-based “Live View” tool that shows all of the patients on a unit and their incidences of high sustained pain over a week. The tool is used for rounding on patients and identifying those needing an immediate interdisciplinary focus.

Project results, Dr. Rizk reported, include improvements in high sustained pain scores on six of seven participating units and average reductions in the number of identified barriers to pain. Hospitalists reported increased comfort with adjusting pain therapies, while patient satisfaction scores with pain management also increased.

“Not everyone has access to an expert like Dr. Portenoy, but we’ve now done the root cause analysis and barriers list,” Dr. Rizk says. “I also think this approach could be applied more widely to other problem areas. We plan to try something similar with geriatrics.”

For more information about the collaborative and its pain problem list, contact Dr. Rizk at DRizk@chpnet.org.

A collaboration between hospitalists and the pain department at Beth Israel Medical Center in New York City is helping hospitalists address moderate to severe pain and complicating factors in their patients.

“The idea was to impart knowledge from a small group of experts to the hospitalists who manage pain in the majority of hospitalized patients,” says Dahlia Rizk, DO, chief of hospital medicine at Beth Israel and lead author on a poster that described the program and was presented at HM13 in Washington, D.C.¹

Dr. Rizk first approached Russell Portenoy, MD, internationally recognized chair of the Department of Pain Management and Palliative Care at Beth Israel, to draw upon his specialized knowledge. Grant funding supported protected time for two hospitalist champions and a nurse practitioner; they reviewed charts on participating units and conducted focus groups with hospitalists to identify barriers to effective pain management. Barriers were compiled into a 56-item menu and shaped the curriculum for weekly training sessions presented by the pain service.

Dr. Portenoy and the project team also established a metric for “high sustained pain,” patients reporting three or more days of three or more episodes of moderate to severe pain, according to the hospital’s standardized pain assessment scale. The information was captured in a computerized, tablet-based “Live View” tool that shows all of the patients on a unit and their incidences of high sustained pain over a week. The tool is used for rounding on patients and identifying those needing an immediate interdisciplinary focus.

Project results, Dr. Rizk reported, include improvements in high sustained pain scores on six of seven participating units and average reductions in the number of identified barriers to pain. Hospitalists reported increased comfort with adjusting pain therapies, while patient satisfaction scores with pain management also increased.

“Not everyone has access to an expert like Dr. Portenoy, but we’ve now done the root cause analysis and barriers list,” Dr. Rizk says. “I also think this approach could be applied more widely to other problem areas. We plan to try something similar with geriatrics.”

For more information about the collaborative and its pain problem list, contact Dr. Rizk at DRizk@chpnet.org.

A collaboration between hospitalists and the pain department at Beth Israel Medical Center in New York City is helping hospitalists address moderate to severe pain and complicating factors in their patients.

“The idea was to impart knowledge from a small group of experts to the hospitalists who manage pain in the majority of hospitalized patients,” says Dahlia Rizk, DO, chief of hospital medicine at Beth Israel and lead author on a poster that described the program and was presented at HM13 in Washington, D.C.¹

Dr. Rizk first approached Russell Portenoy, MD, internationally recognized chair of the Department of Pain Management and Palliative Care at Beth Israel, to draw upon his specialized knowledge. Grant funding supported protected time for two hospitalist champions and a nurse practitioner; they reviewed charts on participating units and conducted focus groups with hospitalists to identify barriers to effective pain management. Barriers were compiled into a 56-item menu and shaped the curriculum for weekly training sessions presented by the pain service.

Dr. Portenoy and the project team also established a metric for “high sustained pain,” patients reporting three or more days of three or more episodes of moderate to severe pain, according to the hospital’s standardized pain assessment scale. The information was captured in a computerized, tablet-based “Live View” tool that shows all of the patients on a unit and their incidences of high sustained pain over a week. The tool is used for rounding on patients and identifying those needing an immediate interdisciplinary focus.

Project results, Dr. Rizk reported, include improvements in high sustained pain scores on six of seven participating units and average reductions in the number of identified barriers to pain. Hospitalists reported increased comfort with adjusting pain therapies, while patient satisfaction scores with pain management also increased.

“Not everyone has access to an expert like Dr. Portenoy, but we’ve now done the root cause analysis and barriers list,” Dr. Rizk says. “I also think this approach could be applied more widely to other problem areas. We plan to try something similar with geriatrics.”

For more information about the collaborative and its pain problem list, contact Dr. Rizk at DRizk@chpnet.org.

Use SHM’s CODE-H Interactive to Avoid Coding Issues

Coding is a part of every hospitalist’s life, but tips from the experts can make that life easier, more efficient, and more compliant. That’s why SHM’s CODE-H program teaches hospitalists and hospitalist group managers and administrators how to stay up to date with the latest in the best

practices of coding and documentation.

On March 20, coding expert Barbara Pierce, CCS-P, ACS-EM, will present an online session on some of the most important coding topics for hospitalists, including:

• Critical care;
• Prolonged services;
• Documentation when working with NPs and PAs;
• Teaching physician rules; and
• Tips to avoid billing issues and potential denials.

This session is the third in a series of seven that cover the full range of coding topics, from developing a compliance plan and internal auditing process to ICD-10, PQRS, and Medicare’s Physician Value-Based Payment Modifier.

CME credits are offered through post-tests following each webinar, and each participant is eligible for up to seven credits throughout the series. Up to 10 individuals in a group can sign up through a single registration.

For more information, visit www.hospitalmedicine.org/codeh.

Use SHM’s CODE-H Interactive to Avoid Coding Issues

Coding is a part of every hospitalist’s life, but tips from the experts can make that life easier, more efficient, and more compliant. That’s why SHM’s CODE-H program teaches hospitalists and hospitalist group managers and administrators how to stay up to date with the latest in the best

practices of coding and documentation.

On March 20, coding expert Barbara Pierce, CCS-P, ACS-EM, will present an online session on some of the most important coding topics for hospitalists, including:

• Critical care;
• Prolonged services;
• Documentation when working with NPs and PAs;
• Teaching physician rules; and
• Tips to avoid billing issues and potential denials.

This session is the third in a series of seven that cover the full range of coding topics, from developing a compliance plan and internal auditing process to ICD-10, PQRS, and Medicare’s Physician Value-Based Payment Modifier.

CME credits are offered through post-tests following each webinar, and each participant is eligible for up to seven credits throughout the series. Up to 10 individuals in a group can sign up through a single registration.

For more information, visit www.hospitalmedicine.org/codeh.

Use SHM’s CODE-H Interactive to Avoid Coding Issues

Coding is a part of every hospitalist’s life, but tips from the experts can make that life easier, more efficient, and more compliant. That’s why SHM’s CODE-H program teaches hospitalists and hospitalist group managers and administrators how to stay up to date with the latest in the best

practices of coding and documentation.

On March 20, coding expert Barbara Pierce, CCS-P, ACS-EM, will present an online session on some of the most important coding topics for hospitalists, including:

• Critical care;
• Prolonged services;
• Documentation when working with NPs and PAs;
• Teaching physician rules; and
• Tips to avoid billing issues and potential denials.

This session is the third in a series of seven that cover the full range of coding topics, from developing a compliance plan and internal auditing process to ICD-10, PQRS, and Medicare’s Physician Value-Based Payment Modifier.

CME credits are offered through post-tests following each webinar, and each participant is eligible for up to seven credits throughout the series. Up to 10 individuals in a group can sign up through a single registration.

For more information, visit www.hospitalmedicine.org/codeh.

BOOST Makes a Difference

For more info, visit www.hospitalmedicine.org/boost.

BOOST Makes a Difference

For more info, visit www.hospitalmedicine.org/boost.

BOOST Makes a Difference

For more info, visit www.hospitalmedicine.org/boost.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting offers something new each year. For HM14, a timely new track dubbed “Bending the Cost Curve” will focus on hospitalists’ role in improving cost effectiveness for the healthcare system as a whole.

“The value equation has always been something that’s near and dear to us,” says HM14 course director Daniel Brotman, MD, SFHM. “What’s different now is that cost shifting to the outpatient setting is something that is now being recognized as a potential unintended consequence of rushing through hospitalizations. And as we’re moving into the accountable-care world, making sure that the cost shifting does not occur…is really important.

“That means that hospitalists need to own the care transition.”

“ The educational component particularly the practice management track—is increasingly important in this era of rapid change. I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual. ”

–Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course

The debut offerings don’t stop there. Three new pre-courses are on this year’s agenda: “Cardiology: What Hospitalists Need to Know as Front-Line Providers,” “Efficient High-Value Evidence-Based Medicine for the Practicing Hospitalist,” and “NP/PA Playbook for Hospital Medicine.”

“As a pre-course director, I think the educational aspect is what sets the tone for the whole meeting,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and co-director for the practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform. “People come looking to improve their clinical skills and their hospitalist groups.”

Pre-courses are critical to the meeting’s educational offerings. In that vein, HM14 is keeping pace with generational reform in care delivery and payment methodologies.

“The educational component—particularly the practice management track—is increasingly important in this era of rapid change,” Flores adds. “I don’t think any hospitalist anywhere in the country can afford to put his or her head in the sand and pretend it’s business as usual.”

To that end, another new feature at HM14 is a panel discussion titled, “Obamacare Is Here: What Does It Mean for You and Your Hospital?” The participants are a who’s who of the specialty’s thought leaders: Centers for Medicare & Medicaid Services chief medical officer Patrick Conway, MD, MSc, FAAP, SFHM; executive director and CEO of the Medical University of South Carolina and former SHM president Patrick Cawley, MD, MHM, FACP; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD.

“The SHM annual meeting is pretty much the only place a hospitalist can go to learn about these changes,” Flores says, “and how to cope with them from a hospitalist’s perspective.”

Richard Quinn is a freelance writer in New Jersey.

Click here to listen to more of our interview with Dr. Hilger

Click here to listen to more of our interview with Dr. Hilger

Click here to listen to more of our interview with Dr. Hilger

Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

Dr. Nelson

Dr. Nelson

The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.

For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.

Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.

Altered Referral Patterns, Division of Labor

A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.

If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.

Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.

When Do Things Get Done?

A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.

She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.

Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.

What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.

John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.

John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.

In a very well written and moving essay, John describes his mother’s care.¹ Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.

It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Reference

1. Maa J. The waits that matter. N Engl J Med. 2011;364(24):2279-2281.

Dr. Nelson

Dr. Nelson

The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.

For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.

Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.

Altered Referral Patterns, Division of Labor

A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.

If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.

Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.

When Do Things Get Done?

A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.

She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.

Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.

What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.

John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.

John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.

In a very well written and moving essay, John describes his mother’s care.¹ Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.

It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Reference

1. Maa J. The waits that matter. N Engl J Med. 2011;364(24):2279-2281.

Dr. Nelson

Dr. Nelson

The accumulated wisdom, research data, and opinions regarding the use of electronic health records (EHRs) are vast. A quick Internet search turns up many informative articles on their positive and negative effects. But I haven’t found many that explicitly review the unanticipated effects EHRs have on who does what in the hospital.

For example, when reports such as admission and discharge notes are done via recorded dictation and transcription, the author would typically dictate where copies of the report should be sent (“copy to Dr. Matheny”) and rely on others to ensure it reached its intended destination. In many hospitals, such reports are now typed directly into the EHR, often using speech recognition software, and it is up to the author to click several buttons to ensure that it is routed to the intended recipients. So now a clerical function, sending reports, is handled by providers. This can be a good thing—reduced clerical staffing costs, faster transmission of reports—but often means that there is no documentation within the report itself of whom it was sent to (i.e., no list of “cc’s”). It also means that when the recipient isn’t easy to find, the report author is likely to give up, and the report may never be sent.

Any hospitalist using an EHR could easily list dozens of similar unanticipated effects, both good and bad. The magnitude and risk of these are difficult to quantify.

Altered Referral Patterns, Division of Labor

A hospitalist-specific side effect of EHR adoption is that they tend to cause many other doctors to resist serving as attending physician, instead asking hospitalists to replace them in that role. Even without EHRs, shifting attending responsibility to hospitalists has been a trend at nearly every hospital for years, but it can be accelerated dramatically at the time of a “go live.” So, in addition to the stress of adapting to the new EHR, hospitalists typically face higher than usual patient volumes resulting from increased referrals from other doctors.

If you’re a hospitalist facing an upcoming “go live,” it would be worth talking to other doctors in multiple specialties regarding your capacity to handle additional work. Keep in mind the possibility of higher than typical winter 2014 patient volumes that could result from patients who are newly insured through health exchanges.

Many factors, in addition to EHRs, are moving physicians away from a willingness to serve as attending, including the complexity of managing inpatient vs. observation status, keeping up with ever-changing documentation, pay-for-performance initiatives, the stress of ED call, and so on. As I’ve written before (see my January 2011 column, “Health IT Hurdles,”), I think effective management of hospital systems is becoming as complicated as safely piloting a jumbo jet. It will be increasingly difficult for doctors in any specialty to stay proficient at “piloting” a hospital unless they do it all or most of the time. And, staying proficient at multiple hospitals simultaneously may not be feasible at some point. We’ll see.

When Do Things Get Done?

A friend of mine, Dr. John Maa, is a general surgeon who was instrumental in establishing one of the first general surgery hospitalist practices. He tells a very personal and tragic story of his mother’s death, which, he has come to believe, might have been made more likely because of the unintended effect of an EHR.

She was a healthy 69-year-old who developed new onset atrial fibrillation and went to “one of the most highly regarded academic medical centers on the West Coast,” albeit not a facility where John was practicing. She was admitted with orders for anticoagulation but spent her first night on a stretcher in the ED because no inpatient bed was available. She went to a hospital room the next day, but her late arrival there delayed the planned transesophageal echo and cardioversion by another day.

Tragically, before the cardioversion could be done, she had a very large embolic stroke that led to brain herniation. A short time later, John and his father made the wrenching decision to discontinue mechanical ventilation. She died 112 hours after walking into the hospital.

What John later learned is that the admission orders written while she was in the ED were put into “sign and hold” status in the hospital’s EHR. Her caregivers had not anticipated a significant delay in moving her to an inpatient bed, and for the 18 or so hours she spent boarding in the ED, her admission orders were not acted on, and anticoagulation was delayed many hours. She might have had the same outcome even if anticoagulation had been started promptly, but it would have been much less likely.

John believes that the “sign and hold” status of the admission orders was a major contributor to the treatment delay. It increased the risk that the ED caregivers never acted on those orders, and may not have even seen them, since the EHR essentially holds them for presentation to the receiving inpatient unit.

John only recognized this vulnerability three years after his mother’s passing, when he underwent the physician training for the same EHR system. The course teachers agreed that this problem could arise if a patient was boarded in the ED for a prolonged period but felt that the responsibility rested with hospital administrators to minimize overcrowding in the ED. John also raised the issue with hospital leadership, who shared his concern but believed that a software remedy should be the solution. Ultimately, the answer may come from medical hospitalists, who recognize that every day and night, patients across America are at risk for a repeat of the incident John’s family suffered nearly five years ago.

In a very well written and moving essay, John describes his mother’s care.¹ Though he doesn’t specifically mention the likely contribution of the “sign and hold” orders, it is one more example of EHR-related confusion that can arise around who does what and when they should do it. Clearly, the same sort of confusion exists in a non-EHR hospital, but it is the EHR-related change in the previous way of doing things that likely increases risk.

It can be very difficult—even impossible—to see all of these issues in advance. Even when acknowledged, the challenges can be difficult to address. But the first step is to recognize a problem, or potential problem, and think carefully about how it should be addressed.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Reference

1. Maa J. The waits that matter. N Engl J Med. 2011;364(24):2279-2281.

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

By now, most hospitalists have at least heard about the Recognition in Focused Practice in Hospital Medicine (RFPHM), which is offered as a variation in certification for internal medicine- and family medicine-trained graduates who are pursuing Maintenance of Certification (MOC). Although the requirements are relatively straightforward, it may not be abundantly clear exactly why a hospitalist would pursue this pathway. As a recent “graduate” of the first cycle of the program, I can testify it is wholly worth the time and energy for the following reasons:

1. The requirements are relatively easy. Table 1 outlines the requirements for eligibility for enrolling in the program through the American Board of Internal Medicine (ABIM); enrollment through the American Board of Family Medicine (ABFM) also is available. These are basic requirements, and most practicing hospitalists will easily qualify simply by doing their daily jobs. Enrollment does require an administrative fee, but many HM programs can—and should—reimburse you for these fees, so be sure to ask if your program will cover the cost.

After enrolling and paying the fee, your next step is to accumulate points toward certification. Of note, the 100 points do not all have to be accumulated prior to sitting for the exam, but accumulating these points generally prepares you for the exam, so it is a good idea to complete this task before the exam, in most circumstances.

The medical knowledge modules can be completed through ABIM/ABFM, the Society of Hospital Medicine (SHM), or the New England Journal of Medicine.¹ A repertoire of clinical and non-clinical modules are offered by ABIM, and there are two modules on quality-patient safety offered by SHM. You can attend a number of pre-courses offered at local-regional-national HM meetings; these modules can be completed individually or in a group setting. A list of available group learning sessions can be found at www.abim.org. You can earn CME credit for completing these modules. Not only are the medical knowledge modules readily available, but they are also well written, are easy to complete, and prepare you well for the exam.

The practice performance modules can be completed through ABIM/ABFM or through a number of medical centers that participate in the American Board of Medical Specialties “Portfolio Program.” For organizations that participate in the program, hospitalists within the organizational network who have completed a quality improvement project may qualify for module credit. A list of these sponsoring organizations can be found at http://mocportfolioprogram.org/approved-portfolio-sponsors.

Hospitalists can earn practice improvement module (PIM) credit for being involved in a number of large collaborative projects, including SHM’s mentored implementation programs (e.g. glycemic control, VTE, and Project BOOST).³

For those completing a PIM through the ABIM, the most straightforward are the self-directed PIM or the completed project PIM.²

2. The exam content is known. Table 2 lists the content categories of the secure exam, published by ABIM, with approximate percentages of the content within overall categories and subcategories. This information helps you focus your efforts in preparing for the exam and is aligned with what most hospitalists practice on a daily basis.

3. The exam preparation is easy. Not only is the content outlined in the blueprint in Table 2, but practice exams are available online from the ABIM and a tutorial can be found at www.abim.org/hospital-medicine-tutorial. This tutorial simulates the actual exam, to enhance preparation and reduce testing anxiety.

4. The exam pass rate is high. Table 3 lists pass rates from the 2010-2012 hospital medicine exam. These pass rates are equivalent to the general medicine exam, and they exceed some of the other specialty exam pass rates.

5. RFPHM is gaining more of the recognition it deserves. Given this growth in recognition, from employers, peers, patients, and maybe even payors, it would serve you well to start the process early, because it is highly likely to gain traction in the coming years.

Join Us

All told, RFPHM enrollment, preparation, and exam completion are straightforward, relatively easy, and worth the time and energy. I hope you join me and the 418 other hospitalists who have pursued this recognition. You will be glad you invested in your future.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. American Board of Internal Medicine. List of self-evaluation modules. Available at: http://www.abim.org/maintenance-of-certification/medical-knowledge/modules.aspx#hosp. Accessed November 27, 2013.
2. American Board of Internal Medicine. List of PIMs from ABIM. Available at: http://www.abim.org/moc/earning-points.aspx. Accessed November 27, 2013.
3. American Board of Internal Medicine. List of PIMs from sponsoring institutions. Available at: http://www.abim.org/moc/earning-points/productinfo-demo-ordering.aspx#aqi. Accessed November 27, 2013.

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

By now, most hospitalists have at least heard about the Recognition in Focused Practice in Hospital Medicine (RFPHM), which is offered as a variation in certification for internal medicine- and family medicine-trained graduates who are pursuing Maintenance of Certification (MOC). Although the requirements are relatively straightforward, it may not be abundantly clear exactly why a hospitalist would pursue this pathway. As a recent “graduate” of the first cycle of the program, I can testify it is wholly worth the time and energy for the following reasons:

1. The requirements are relatively easy. Table 1 outlines the requirements for eligibility for enrolling in the program through the American Board of Internal Medicine (ABIM); enrollment through the American Board of Family Medicine (ABFM) also is available. These are basic requirements, and most practicing hospitalists will easily qualify simply by doing their daily jobs. Enrollment does require an administrative fee, but many HM programs can—and should—reimburse you for these fees, so be sure to ask if your program will cover the cost.

After enrolling and paying the fee, your next step is to accumulate points toward certification. Of note, the 100 points do not all have to be accumulated prior to sitting for the exam, but accumulating these points generally prepares you for the exam, so it is a good idea to complete this task before the exam, in most circumstances.

The medical knowledge modules can be completed through ABIM/ABFM, the Society of Hospital Medicine (SHM), or the New England Journal of Medicine.¹ A repertoire of clinical and non-clinical modules are offered by ABIM, and there are two modules on quality-patient safety offered by SHM. You can attend a number of pre-courses offered at local-regional-national HM meetings; these modules can be completed individually or in a group setting. A list of available group learning sessions can be found at www.abim.org. You can earn CME credit for completing these modules. Not only are the medical knowledge modules readily available, but they are also well written, are easy to complete, and prepare you well for the exam.

The practice performance modules can be completed through ABIM/ABFM or through a number of medical centers that participate in the American Board of Medical Specialties “Portfolio Program.” For organizations that participate in the program, hospitalists within the organizational network who have completed a quality improvement project may qualify for module credit. A list of these sponsoring organizations can be found at http://mocportfolioprogram.org/approved-portfolio-sponsors.

Hospitalists can earn practice improvement module (PIM) credit for being involved in a number of large collaborative projects, including SHM’s mentored implementation programs (e.g. glycemic control, VTE, and Project BOOST).³

For those completing a PIM through the ABIM, the most straightforward are the self-directed PIM or the completed project PIM.²

2. The exam content is known. Table 2 lists the content categories of the secure exam, published by ABIM, with approximate percentages of the content within overall categories and subcategories. This information helps you focus your efforts in preparing for the exam and is aligned with what most hospitalists practice on a daily basis.

3. The exam preparation is easy. Not only is the content outlined in the blueprint in Table 2, but practice exams are available online from the ABIM and a tutorial can be found at www.abim.org/hospital-medicine-tutorial. This tutorial simulates the actual exam, to enhance preparation and reduce testing anxiety.

4. The exam pass rate is high. Table 3 lists pass rates from the 2010-2012 hospital medicine exam. These pass rates are equivalent to the general medicine exam, and they exceed some of the other specialty exam pass rates.

5. RFPHM is gaining more of the recognition it deserves. Given this growth in recognition, from employers, peers, patients, and maybe even payors, it would serve you well to start the process early, because it is highly likely to gain traction in the coming years.

Join Us

All told, RFPHM enrollment, preparation, and exam completion are straightforward, relatively easy, and worth the time and energy. I hope you join me and the 418 other hospitalists who have pursued this recognition. You will be glad you invested in your future.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. American Board of Internal Medicine. List of self-evaluation modules. Available at: http://www.abim.org/maintenance-of-certification/medical-knowledge/modules.aspx#hosp. Accessed November 27, 2013.
2. American Board of Internal Medicine. List of PIMs from ABIM. Available at: http://www.abim.org/moc/earning-points.aspx. Accessed November 27, 2013.
3. American Board of Internal Medicine. List of PIMs from sponsoring institutions. Available at: http://www.abim.org/moc/earning-points/productinfo-demo-ordering.aspx#aqi. Accessed November 27, 2013.

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

Dr. Scheurer

By now, most hospitalists have at least heard about the Recognition in Focused Practice in Hospital Medicine (RFPHM), which is offered as a variation in certification for internal medicine- and family medicine-trained graduates who are pursuing Maintenance of Certification (MOC). Although the requirements are relatively straightforward, it may not be abundantly clear exactly why a hospitalist would pursue this pathway. As a recent “graduate” of the first cycle of the program, I can testify it is wholly worth the time and energy for the following reasons:

1. The requirements are relatively easy. Table 1 outlines the requirements for eligibility for enrolling in the program through the American Board of Internal Medicine (ABIM); enrollment through the American Board of Family Medicine (ABFM) also is available. These are basic requirements, and most practicing hospitalists will easily qualify simply by doing their daily jobs. Enrollment does require an administrative fee, but many HM programs can—and should—reimburse you for these fees, so be sure to ask if your program will cover the cost.

After enrolling and paying the fee, your next step is to accumulate points toward certification. Of note, the 100 points do not all have to be accumulated prior to sitting for the exam, but accumulating these points generally prepares you for the exam, so it is a good idea to complete this task before the exam, in most circumstances.

The medical knowledge modules can be completed through ABIM/ABFM, the Society of Hospital Medicine (SHM), or the New England Journal of Medicine.¹ A repertoire of clinical and non-clinical modules are offered by ABIM, and there are two modules on quality-patient safety offered by SHM. You can attend a number of pre-courses offered at local-regional-national HM meetings; these modules can be completed individually or in a group setting. A list of available group learning sessions can be found at www.abim.org. You can earn CME credit for completing these modules. Not only are the medical knowledge modules readily available, but they are also well written, are easy to complete, and prepare you well for the exam.

The practice performance modules can be completed through ABIM/ABFM or through a number of medical centers that participate in the American Board of Medical Specialties “Portfolio Program.” For organizations that participate in the program, hospitalists within the organizational network who have completed a quality improvement project may qualify for module credit. A list of these sponsoring organizations can be found at http://mocportfolioprogram.org/approved-portfolio-sponsors.

Hospitalists can earn practice improvement module (PIM) credit for being involved in a number of large collaborative projects, including SHM’s mentored implementation programs (e.g. glycemic control, VTE, and Project BOOST).³

For those completing a PIM through the ABIM, the most straightforward are the self-directed PIM or the completed project PIM.²

2. The exam content is known. Table 2 lists the content categories of the secure exam, published by ABIM, with approximate percentages of the content within overall categories and subcategories. This information helps you focus your efforts in preparing for the exam and is aligned with what most hospitalists practice on a daily basis.

3. The exam preparation is easy. Not only is the content outlined in the blueprint in Table 2, but practice exams are available online from the ABIM and a tutorial can be found at www.abim.org/hospital-medicine-tutorial. This tutorial simulates the actual exam, to enhance preparation and reduce testing anxiety.

4. The exam pass rate is high. Table 3 lists pass rates from the 2010-2012 hospital medicine exam. These pass rates are equivalent to the general medicine exam, and they exceed some of the other specialty exam pass rates.

5. RFPHM is gaining more of the recognition it deserves. Given this growth in recognition, from employers, peers, patients, and maybe even payors, it would serve you well to start the process early, because it is highly likely to gain traction in the coming years.

Join Us

All told, RFPHM enrollment, preparation, and exam completion are straightforward, relatively easy, and worth the time and energy. I hope you join me and the 418 other hospitalists who have pursued this recognition. You will be glad you invested in your future.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. American Board of Internal Medicine. List of self-evaluation modules. Available at: http://www.abim.org/maintenance-of-certification/medical-knowledge/modules.aspx#hosp. Accessed November 27, 2013.
2. American Board of Internal Medicine. List of PIMs from ABIM. Available at: http://www.abim.org/moc/earning-points.aspx. Accessed November 27, 2013.
3. American Board of Internal Medicine. List of PIMs from sponsoring institutions. Available at: http://www.abim.org/moc/earning-points/productinfo-demo-ordering.aspx#aqi. Accessed November 27, 2013.

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

What makes a great doctor? Heck if I know. Maybe it’s like pornography. A great physician, well, “You know one when you see one.” That approach worked from the time of Hippocrates until the recent past, when the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and others embarked on programs to measure and report physician quality. Of course, bodies like the American Board of Internal Medicine have been certifying physicians for a long time.

Ongoing Professional Practice Evaluation (OPPE) is one such measurement program, now over four years old, with standards put forth by the Joint Commission in an effort to monitor individual physician—and non-physician provider—performance across a number of domains. The program requires accredited hospitals to monitor and report performance to the physician/provider at least every 11 months, and to use such information in the credentialing process.

This year, I received two OPPE reports, causing me to reflect on how helpful these reports are in judging and improving the quality of my practice. Before I discuss some of the “grades” I received, let me start with my conclusion: Physician quality measurement is in its infancy, and the measures are at best “directional” for most physicians, including hospitalists. Some measurement is better than none at all, however, and selected measures, such as surgical site infection and other measures of harm, may be grounds for closer monitoring, or even corrective action, of a physician’s practice. Unfortunately, my stance that OPPE quality measures are “directional” might not help a physician whose privileges are on the line.

Attribution

For hospitalists, the first concern in measuring and reporting quality is, “How can I attribute quality to an individual hospitalist, when several different hospitalists see the patient?” My perspective is that unless a quality measure can be attributed to an individual hospitalist (e.g. discharge medication reconciliation), it should be attributed at the group level.

However, the OPPE program is specifically intended to address the individual physician/provider for purposes of credentialing, and group attribution is a non-starter. In my performance examples below, I believe that attributing outcomes like mortality, readmissions, or resource utilization to individual hospitalists does not make sense—and is probably unfair.

Resource Utilization

The report lists my performance (Practitioner) compared to an Internal Comparison Group for a specified time period (see Figure 1). The comparison group is described as “practitioners in your specialty...from within your health system.” My data were generated based on only 45 cases (I see patients only part time), while the comparison group was based on 4,530 cases. What I take home from this is that, for cost/resource, I look favorable in “supplies” and “pharmacy”; for most of the others, I’m expensive in comparison.

Will this change my practice? Maybe I will think twice about incurring laboratory or pharmacy costs, but I can’t say I am going to fundamentally rethink how or what I order. And I take all these data with a grain of salt, because I share responsibility for patients with several other hospitalists.

Readmissions

My 30-day readmissions performance (see Figure 2) is weak compared to the Internal Comp Group, which I defined above, and the Peer group, which in my report is defined as derived from practitioners at facilities with 501 beds or more (my facility has 700-plus beds). I accept the “directional” nature of the data, meaning that it provides a general idea but not a precise measurement, and vow to reflect on the processes underlying my approach to hospital discharge (teach back, medication reconciliation, PCP communication, and so on).

Mortality

For this category (see Figure 3), I’m looking better. The blue bar is “observed,” while the red bar is “expected.” Although my patients are sicker (higher “expected” mortality), my “observed” mortality is lower than the comparison group. I’m not sure why my observed mortality is lower, but I’m convinced that part of the reason for a higher expected mortality is that my documentation is better than the comparison group.

Will OPPE Change My Practice?

There are other data in my report, including process (core) measures, length of stay, hospital-acquired conditions, and patient flow measures. The OPPE report is but one of a growing number of physician report cards: The Massachusetts Board of Medicine, Physician Compare (CMS), and Health Grades are just a few of the organizations that have public websites reporting my performance. Perhaps at this stage, the primary impact of these reports is through the oft-invoked “Hawthorne Effect,” where subjects modify behavior simply because they are being observed, as opposed to any particular piece of feedback.

My sense is that hospitalists are particularly open to the type of feedback offered in OPPE and similar reports, as long as the data are credible, even if reflecting group level performance. The 2012 SHM State of Hospital Medicine survey shows that the percent of hospitalist compensation based on performance (other than production/billings) increased to 7% from 4% in 2011. It seems that performance measurement with consequences, be it for credentialing or compensation, is here to stay.

Dr. Whitcombis Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

What makes a great doctor? Heck if I know. Maybe it’s like pornography. A great physician, well, “You know one when you see one.” That approach worked from the time of Hippocrates until the recent past, when the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and others embarked on programs to measure and report physician quality. Of course, bodies like the American Board of Internal Medicine have been certifying physicians for a long time.

Ongoing Professional Practice Evaluation (OPPE) is one such measurement program, now over four years old, with standards put forth by the Joint Commission in an effort to monitor individual physician—and non-physician provider—performance across a number of domains. The program requires accredited hospitals to monitor and report performance to the physician/provider at least every 11 months, and to use such information in the credentialing process.

This year, I received two OPPE reports, causing me to reflect on how helpful these reports are in judging and improving the quality of my practice. Before I discuss some of the “grades” I received, let me start with my conclusion: Physician quality measurement is in its infancy, and the measures are at best “directional” for most physicians, including hospitalists. Some measurement is better than none at all, however, and selected measures, such as surgical site infection and other measures of harm, may be grounds for closer monitoring, or even corrective action, of a physician’s practice. Unfortunately, my stance that OPPE quality measures are “directional” might not help a physician whose privileges are on the line.

Attribution

For hospitalists, the first concern in measuring and reporting quality is, “How can I attribute quality to an individual hospitalist, when several different hospitalists see the patient?” My perspective is that unless a quality measure can be attributed to an individual hospitalist (e.g. discharge medication reconciliation), it should be attributed at the group level.

However, the OPPE program is specifically intended to address the individual physician/provider for purposes of credentialing, and group attribution is a non-starter. In my performance examples below, I believe that attributing outcomes like mortality, readmissions, or resource utilization to individual hospitalists does not make sense—and is probably unfair.

Resource Utilization

The report lists my performance (Practitioner) compared to an Internal Comparison Group for a specified time period (see Figure 1). The comparison group is described as “practitioners in your specialty...from within your health system.” My data were generated based on only 45 cases (I see patients only part time), while the comparison group was based on 4,530 cases. What I take home from this is that, for cost/resource, I look favorable in “supplies” and “pharmacy”; for most of the others, I’m expensive in comparison.

Will this change my practice? Maybe I will think twice about incurring laboratory or pharmacy costs, but I can’t say I am going to fundamentally rethink how or what I order. And I take all these data with a grain of salt, because I share responsibility for patients with several other hospitalists.

Readmissions

My 30-day readmissions performance (see Figure 2) is weak compared to the Internal Comp Group, which I defined above, and the Peer group, which in my report is defined as derived from practitioners at facilities with 501 beds or more (my facility has 700-plus beds). I accept the “directional” nature of the data, meaning that it provides a general idea but not a precise measurement, and vow to reflect on the processes underlying my approach to hospital discharge (teach back, medication reconciliation, PCP communication, and so on).

Mortality

For this category (see Figure 3), I’m looking better. The blue bar is “observed,” while the red bar is “expected.” Although my patients are sicker (higher “expected” mortality), my “observed” mortality is lower than the comparison group. I’m not sure why my observed mortality is lower, but I’m convinced that part of the reason for a higher expected mortality is that my documentation is better than the comparison group.

Will OPPE Change My Practice?

There are other data in my report, including process (core) measures, length of stay, hospital-acquired conditions, and patient flow measures. The OPPE report is but one of a growing number of physician report cards: The Massachusetts Board of Medicine, Physician Compare (CMS), and Health Grades are just a few of the organizations that have public websites reporting my performance. Perhaps at this stage, the primary impact of these reports is through the oft-invoked “Hawthorne Effect,” where subjects modify behavior simply because they are being observed, as opposed to any particular piece of feedback.

My sense is that hospitalists are particularly open to the type of feedback offered in OPPE and similar reports, as long as the data are credible, even if reflecting group level performance. The 2012 SHM State of Hospital Medicine survey shows that the percent of hospitalist compensation based on performance (other than production/billings) increased to 7% from 4% in 2011. It seems that performance measurement with consequences, be it for credentialing or compensation, is here to stay.

Dr. Whitcombis Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

Dr. Whitcomb

What makes a great doctor? Heck if I know. Maybe it’s like pornography. A great physician, well, “You know one when you see one.” That approach worked from the time of Hippocrates until the recent past, when the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and others embarked on programs to measure and report physician quality. Of course, bodies like the American Board of Internal Medicine have been certifying physicians for a long time.

Ongoing Professional Practice Evaluation (OPPE) is one such measurement program, now over four years old, with standards put forth by the Joint Commission in an effort to monitor individual physician—and non-physician provider—performance across a number of domains. The program requires accredited hospitals to monitor and report performance to the physician/provider at least every 11 months, and to use such information in the credentialing process.

This year, I received two OPPE reports, causing me to reflect on how helpful these reports are in judging and improving the quality of my practice. Before I discuss some of the “grades” I received, let me start with my conclusion: Physician quality measurement is in its infancy, and the measures are at best “directional” for most physicians, including hospitalists. Some measurement is better than none at all, however, and selected measures, such as surgical site infection and other measures of harm, may be grounds for closer monitoring, or even corrective action, of a physician’s practice. Unfortunately, my stance that OPPE quality measures are “directional” might not help a physician whose privileges are on the line.

Attribution

For hospitalists, the first concern in measuring and reporting quality is, “How can I attribute quality to an individual hospitalist, when several different hospitalists see the patient?” My perspective is that unless a quality measure can be attributed to an individual hospitalist (e.g. discharge medication reconciliation), it should be attributed at the group level.

However, the OPPE program is specifically intended to address the individual physician/provider for purposes of credentialing, and group attribution is a non-starter. In my performance examples below, I believe that attributing outcomes like mortality, readmissions, or resource utilization to individual hospitalists does not make sense—and is probably unfair.

Resource Utilization

The report lists my performance (Practitioner) compared to an Internal Comparison Group for a specified time period (see Figure 1). The comparison group is described as “practitioners in your specialty...from within your health system.” My data were generated based on only 45 cases (I see patients only part time), while the comparison group was based on 4,530 cases. What I take home from this is that, for cost/resource, I look favorable in “supplies” and “pharmacy”; for most of the others, I’m expensive in comparison.

Will this change my practice? Maybe I will think twice about incurring laboratory or pharmacy costs, but I can’t say I am going to fundamentally rethink how or what I order. And I take all these data with a grain of salt, because I share responsibility for patients with several other hospitalists.

Readmissions

My 30-day readmissions performance (see Figure 2) is weak compared to the Internal Comp Group, which I defined above, and the Peer group, which in my report is defined as derived from practitioners at facilities with 501 beds or more (my facility has 700-plus beds). I accept the “directional” nature of the data, meaning that it provides a general idea but not a precise measurement, and vow to reflect on the processes underlying my approach to hospital discharge (teach back, medication reconciliation, PCP communication, and so on).

Mortality

For this category (see Figure 3), I’m looking better. The blue bar is “observed,” while the red bar is “expected.” Although my patients are sicker (higher “expected” mortality), my “observed” mortality is lower than the comparison group. I’m not sure why my observed mortality is lower, but I’m convinced that part of the reason for a higher expected mortality is that my documentation is better than the comparison group.

Will OPPE Change My Practice?

There are other data in my report, including process (core) measures, length of stay, hospital-acquired conditions, and patient flow measures. The OPPE report is but one of a growing number of physician report cards: The Massachusetts Board of Medicine, Physician Compare (CMS), and Health Grades are just a few of the organizations that have public websites reporting my performance. Perhaps at this stage, the primary impact of these reports is through the oft-invoked “Hawthorne Effect,” where subjects modify behavior simply because they are being observed, as opposed to any particular piece of feedback.

My sense is that hospitalists are particularly open to the type of feedback offered in OPPE and similar reports, as long as the data are credible, even if reflecting group level performance. The 2012 SHM State of Hospital Medicine survey shows that the percent of hospitalist compensation based on performance (other than production/billings) increased to 7% from 4% in 2011. It seems that performance measurement with consequences, be it for credentialing or compensation, is here to stay.

Dr. Whitcombis Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.

As many hospitalists are probably acutely aware, the Centers for Medicare & Medicaid Services (CMS) is putting a new rule into effect that will greatly impact how inpatient admission decisions are made. The rule, known as the “two-midnight rule,” states that if the admitting practitioner admits a Medicare beneficiary as an inpatient with the reasonable expectation that the beneficiary will require care that “crosses two midnights” and this decision is justified in the medical record, Medicare Part A payment is “generally appropriate.”

While there are multiple caveats, exceptions, and details, this rule can be simply articulated: If the admitting physician feels a patient will be in the hospital for a period longer than two midnights and the medical record supports this determination, the patient is an inpatient. Stays expected to be shorter than two midnights should be under observation status.

This new policy is an attempt to respond both to hospital calls for more guidance about when a beneficiary is appropriately treated as an inpatient—and paid by Medicare—and concerns about increasingly long hospital stays under observation status. Most hospitalists wrestle with status determination issues on a daily basis.

SHM is aware of the struggle and has been advocating on behalf of hospitalists to help shape observation status and the two-midnight rule. When the rule was first proposed, SHM voiced serious concerns about its utility and how it was unlikely to solve the overall confusion surrounding inpatient status determinations. Nevertheless, CMS finalized the rule as an attempt to begin addressing the problem.

Faced with an increasingly loud chorus of providers and hospitals concerned about the implementation of the new policy, CMS agreed to delay full enforcement from the original date of Oct. 1, 2013, until March 31, 2014.

During the delayed enforcement period, hospitals will be expected to begin implementing the two-midnight rule, and auditors will be giving hospitals non-punitive feedback on their application of the policy. To accomplish this, CMS is instructing Medicare Administrative Contractors (MACs) to review a sample of 10 to 25 inpatient hospital claims spanning less than two midnights after admission for each hospital. This probe sample will be used to assist hospitals with implementing the new requirements correctly. To give an additional level of comfort during this adjustment period, CMS has announced that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014.

Unfortunately, beyond the vague guidance CMS has offered thus far, there is no foolproof guide to establishing new hospital admissions policies that comply with the rule. As a result, there likely will be wide variation among hospitals.

To assist in sorting out the confusion, SHM will be hosting a webinar this month with case studies from several hospitals. The focus will be on the internal processes each hospital is using to implement the rule and how they were developed. Sharing and learning from national implementation experiences is a valuable way for hospitalists to gain new perspectives and to bring those experiences to their home institutions when considering their own roles in meeting the new admissions criteria head on.

For more information about the webinar and to register, visit www.hospitalmedicine.org today.

Josh Boswell is SHM’s senior manager of government relations.