Quality

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

 

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

 

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

 

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

 

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

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

 

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

 

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

 

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

 

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

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

 

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

 

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

 

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

 

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

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

 

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

 

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

 

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

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.

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

Seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, modeled after Project BOOST and sponsored by SHM and the Hospital Association of Southern California (HASC), reported on their experience at a June meeting in Montebello, Calif. Quality teams from four of the seven hospitals demonstrated reductions in readmission rates ranging from 24% to 55%. The other three hospitals are still implementing quality processes and are just now starting to see measurable results.

Several of the participating hospitals do not employ traditional hospitalist services. However, all seven benefit from mentoring by Project BOOST experts and have adopted a number of its approaches and techniques: 72-hour follow-up calls to discharged patients, the use of discharge advocates, medication reconciliation at time of discharge, enhanced discharge planning, and BOOST’s “8Ps” patient risk stratification tool. Another popular approach in use is the “teachback” communication technique, in which patients are asked to repeat in their own words what they understand the professional has told them about their condition and self-care.

One reason many Southern California hospitals do not have a strong hospitalist presence is the widespread prevalence of independent practice associations (IPAs), which often designate members of their medical groups to fill the hospitalist role for patients at a given hospital, says Z. Joseph Wanski, MD, FA

CE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care will be testing the use of hospitalists at some of its contracted acute-care facilities starting in July. (Click here to listen to more of Dr. Wanski’s interview.)

At Harbor UCLA Medical Center in Torrance, a major safety-net facility for Los Angeles County, the readmissions team initially focused on heart failure patients and was able to demonstrate a 5.5% decrease in readmissions for all heart failure patients at a time when readmissions for the hospital as a whole remained the same. The team built relationships with outside partners, including a nearby adult daycare center, home health agencies, and a care-transitions coach while emphasizing early identification of patients for referral to a heart failure disease management registry. The readmissions team also was instrumental in developing the Cardiovascular Open Access Rapid Evaluation (CORE) service, an observation unit for heart failure patients aimed at allieviating ED overcrowding.

“Hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the full-time Project BOOST facilitator at Valley Presbyterian Hospital in Van Nuys. “They see a lot of our patients in their offices.”

Three Valley Presbyterian physicians who work part-time as hospitalists and maintain office practices have agreed to carve out time to see patients who are going home without scheduled appointments with their primary-care physicians (PCPs) within seven days of discharge.

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments,” says Quintero, adding that such patients often decline the hospital team’s offers for help. The readmissions team at Valley Presbyterian is redesigning its clinical multidisciplinary rounds using a rounding script focusing more on discharge planning in rounding.

Larry Beresford is a freelance writer in Oakland, Calif.

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

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

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

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

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

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

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

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

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

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

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

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

 

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

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

Moving Ahead

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

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

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

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

Reference

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

 

 

 

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

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

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

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

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

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

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

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

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

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

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

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

 

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

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

Moving Ahead

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

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

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

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

Reference

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

 

 

 

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

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

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

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

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

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

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

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

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

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

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

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

 

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

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

Moving Ahead

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

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

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

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

Reference

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

 

 

 

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

 

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

 

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

 

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

 

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

 

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

 

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

For hospitalists ready to take the national stage at HM13 next spring in Washington, D.C., it's not too early to be thinking about submissions for SHM's Annual Awards of Excellence and SHM's Research, Innovation, and Clinical Vignettes (RIV) poster competition. In fact, many winners have gone on to become SHM committee chairs, board members, and board presidents.

SHM will begin accepting submissions for both the Awards of Excellence and the RIV poster contest this month. Submissions will be accepted through October.

For more information, visit www.hospitalmedicine.org.

For hospitalists ready to take the national stage at HM13 next spring in Washington, D.C., it's not too early to be thinking about submissions for SHM's Annual Awards of Excellence and SHM's Research, Innovation, and Clinical Vignettes (RIV) poster competition. In fact, many winners have gone on to become SHM committee chairs, board members, and board presidents.

SHM will begin accepting submissions for both the Awards of Excellence and the RIV poster contest this month. Submissions will be accepted through October.

For more information, visit www.hospitalmedicine.org.

For hospitalists ready to take the national stage at HM13 next spring in Washington, D.C., it's not too early to be thinking about submissions for SHM's Annual Awards of Excellence and SHM's Research, Innovation, and Clinical Vignettes (RIV) poster competition. In fact, many winners have gone on to become SHM committee chairs, board members, and board presidents.

SHM will begin accepting submissions for both the Awards of Excellence and the RIV poster contest this month. Submissions will be accepted through October.

For more information, visit www.hospitalmedicine.org.

The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.¹ The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.

This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.

Reference

1. Connolly ES Jr., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-1737.

The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.¹ The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.

This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.

Reference

1. Connolly ES Jr., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-1737.

The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.¹ The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.

This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.

Reference

1. Connolly ES Jr., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-1737.

Take a minute to recall your last credit-card statement. On it, say, is the hotel charge from your last out-of-town CME excursion. Below the total charge you were expecting is a separate line-item charge of $75 for a “recreational fee.” Puzzled, you call the hotel. They inform you that because you used the gym and pool—accessed with your room key—they levied the fee. No signs, alerts, or postings to denote such a policy, you innocently expected inclusive use of the facilities in the price of your visit.

Capture the emotion of that moment. It is likely your heart will race and you will think to yourself, “Get me the manager!”

Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing Medicare patients under observation, rather than inpatient, status. This is to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change and, much in the same way as with our hotel charge, they also experience sticker shock when they get their bills. It is leading to confusion among providers, and consternation within the Medicare recipient community.

Why is this occurring? The dilemma stems from Medicare payments and the key distinction between inpatient coverage (Part A) and outpatient coverage (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation—sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit can mean that beneficiary charges are different. This could result in discrete and sometimes jolting copayments and deductibles for drugs and services.

Worse, if beneficiaries require a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because they never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and, consequently, tempers are rising.

The rules for Medicare Advantage enrollees, who make up 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional fee-for-service in their policies, and, consequently, no exemplar of success in this realm exits.

Hospitals have increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists are often left to navigate without a compass. Again, fear of fraud and penalties places hospitals—and, indirectly, hospitalists, who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which might change in real time during the stay and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices as well as beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after a stay.

Hospitalists, of course, want direction on coding and an understanding of the impact their decisions will have on patients and subspecialty colleagues. To that end, Patrick Conway, MD, SFHM, chief medical officer for the Centers for Medicare & Medicaid (CMS), offers some enlightenment on this matter:

Q: Is it tenable to keep the current system in place? However, as a fix, require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet-to-be determined manner?

A: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for coverage for beneficiaries post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask!” to educate beneficiaries on this issue. The pamphlet can found at http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf.

 

Q: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?

A: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary care, emergency medicine, and/or hospital medicine clinician.

Q: Before the U.S. healthcare system matures to a more integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

A: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

I expect we will hear more from Medicare in the near-term on this matter. Stay tuned.

For more about the patient’s perspective on this issue, please see Brad’s blog: www.hospitalmedicine.org/pmblog.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Take a minute to recall your last credit-card statement. On it, say, is the hotel charge from your last out-of-town CME excursion. Below the total charge you were expecting is a separate line-item charge of $75 for a “recreational fee.” Puzzled, you call the hotel. They inform you that because you used the gym and pool—accessed with your room key—they levied the fee. No signs, alerts, or postings to denote such a policy, you innocently expected inclusive use of the facilities in the price of your visit.

Capture the emotion of that moment. It is likely your heart will race and you will think to yourself, “Get me the manager!”

Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing Medicare patients under observation, rather than inpatient, status. This is to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change and, much in the same way as with our hotel charge, they also experience sticker shock when they get their bills. It is leading to confusion among providers, and consternation within the Medicare recipient community.

Why is this occurring? The dilemma stems from Medicare payments and the key distinction between inpatient coverage (Part A) and outpatient coverage (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation—sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit can mean that beneficiary charges are different. This could result in discrete and sometimes jolting copayments and deductibles for drugs and services.

Worse, if beneficiaries require a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because they never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and, consequently, tempers are rising.

The rules for Medicare Advantage enrollees, who make up 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional fee-for-service in their policies, and, consequently, no exemplar of success in this realm exits.

Hospitals have increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists are often left to navigate without a compass. Again, fear of fraud and penalties places hospitals—and, indirectly, hospitalists, who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which might change in real time during the stay and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices as well as beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after a stay.

Hospitalists, of course, want direction on coding and an understanding of the impact their decisions will have on patients and subspecialty colleagues. To that end, Patrick Conway, MD, SFHM, chief medical officer for the Centers for Medicare & Medicaid (CMS), offers some enlightenment on this matter:

Q: Is it tenable to keep the current system in place? However, as a fix, require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet-to-be determined manner?

A: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for coverage for beneficiaries post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask!” to educate beneficiaries on this issue. The pamphlet can found at http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf.

 

Q: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?

A: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary care, emergency medicine, and/or hospital medicine clinician.

Q: Before the U.S. healthcare system matures to a more integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

A: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

I expect we will hear more from Medicare in the near-term on this matter. Stay tuned.

For more about the patient’s perspective on this issue, please see Brad’s blog: www.hospitalmedicine.org/pmblog.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Take a minute to recall your last credit-card statement. On it, say, is the hotel charge from your last out-of-town CME excursion. Below the total charge you were expecting is a separate line-item charge of $75 for a “recreational fee.” Puzzled, you call the hotel. They inform you that because you used the gym and pool—accessed with your room key—they levied the fee. No signs, alerts, or postings to denote such a policy, you innocently expected inclusive use of the facilities in the price of your visit.

Capture the emotion of that moment. It is likely your heart will race and you will think to yourself, “Get me the manager!”

Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing Medicare patients under observation, rather than inpatient, status. This is to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change and, much in the same way as with our hotel charge, they also experience sticker shock when they get their bills. It is leading to confusion among providers, and consternation within the Medicare recipient community.

Why is this occurring? The dilemma stems from Medicare payments and the key distinction between inpatient coverage (Part A) and outpatient coverage (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation—sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit can mean that beneficiary charges are different. This could result in discrete and sometimes jolting copayments and deductibles for drugs and services.

Worse, if beneficiaries require a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because they never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and, consequently, tempers are rising.

The rules for Medicare Advantage enrollees, who make up 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional fee-for-service in their policies, and, consequently, no exemplar of success in this realm exits.

Hospitals have increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists are often left to navigate without a compass. Again, fear of fraud and penalties places hospitals—and, indirectly, hospitalists, who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which might change in real time during the stay and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices as well as beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after a stay.

Hospitalists, of course, want direction on coding and an understanding of the impact their decisions will have on patients and subspecialty colleagues. To that end, Patrick Conway, MD, SFHM, chief medical officer for the Centers for Medicare & Medicaid (CMS), offers some enlightenment on this matter:

Q: Is it tenable to keep the current system in place? However, as a fix, require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet-to-be determined manner?

A: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for coverage for beneficiaries post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask!” to educate beneficiaries on this issue. The pamphlet can found at http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf.

 

Q: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?

A: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary care, emergency medicine, and/or hospital medicine clinician.

Q: Before the U.S. healthcare system matures to a more integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

A: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

I expect we will hear more from Medicare in the near-term on this matter. Stay tuned.

For more about the patient’s perspective on this issue, please see Brad’s blog: www.hospitalmedicine.org/pmblog.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.