QI Initiatives

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Only about a third of ideal candidates with heart failure are currently treated with [aldosterone antagonists], even though it markedly improves outcome and is Class I-recommended in the guidelines.

—Gregg Fonarow, MD, co-chief, University of California at Los Angeles division of cardiology, chair, American Heart Association’s Get With The Guidelines program steering committee

You might not have done a fellowship in cardiology, but quite often you probably feel like a cardiologist. Hospitalists frequently attend to patients on observation for heart problems and help manage even the most complex patients.

Often, you are working alongside the cardiologist. But other times, you’re on your own. Hospitalists are expected to carry an increasingly heavy load when it comes to heart-failure patients and many other kinds of patients with specialized disorders. It can be hard to keep up with what you need to know.

Top Twelve

1. Recognize the new importance of beta-blockers for heart failure, and go with the best of them.
2. It’s not readmissions that are the problem—it’s avoidable readmissions.
3. New interventional technologies will mean more complex patients, so be ready.
4. Aldosterone antagonists, though probably underutilized, can be very effective but require caution.
5. Switching from IV diuretics to an oral regimen calls for careful monitoring.
6. Patients with heart failure with preserved ejection fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.
7. Inotropic agents can do more harm than good.
8. Pay attention to the ins and outs of new antiplatelet therapies.
9. Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.
10. Some non-STEMI patients might benefit from getting to the catheterization lab quickly.
11. Beware the idiosyncrasies of new anticoagulants.
12. Be cognizant of stent thrombosis and how to manage it.

The Hospitalist spoke to several cardiologists about the latest in treatments, technologies, and HM’s role in the system of care. The following are their suggestions for what you really need to know about treating patients with heart conditions.

1) Recognize the new importance of beta-blockers for heart failure, and go with the best of them.

Angiotensin converting enzyme inhibitors and angiotensive receptor blockers have been part of the Centers for Medicare & Medicaid Services’ (CMS) core measures for heart failure for a long time, but beta-blockers at hospital discharge only recently have been added as American College of Cardiology/American Heart Association/American Medical Association–Physician Consortium for Performance Improvement measures for heart failure.¹

“For those with heart failure and reduced left ventricular ejection fraction, very old and outdated concepts would have talked about potentially holding the beta-blocker during hospitalization for heart failure—or not initiating until the patient was an outpatient,” says Gregg Fonarow, MD, co-chief of the University of California at Los Angeles’ division of cardiology and chair of the steering committee for the American Heart Association’s Get With The Guidelines program. “[But] the guidelines and evidence, and often performance measures, linked to them are now explicit about initiating or maintaining beta-blockers during the heart-failure hospitalization.”

Beta-blockers should be initiated as patients are stabilized before discharge. Dr. Fonarow suggests hospitalists use only one of the three evidence-based therapies: carvedilol, metoprolol succinate, or bisoprolol.

“Many physicians have been using metoprolol tartrate or atenolol in heart-failure patients,” Dr. Fonarow says. “These are not known to improve clinical outcomes. So here’s an example where the specific medication is absolutely, critically important.”

2) It’s not readmissions that are the problem—it’s avoidable readmissions.

“The modifier is very important,” says Clyde Yancy, MD, chief of the division of cardiology at the Northwestern University Feinberg School of Medicine in Chicago. “Heart failure continues to be a problematic disease. Many patients now do really well, but some do not. Those patients are symptomatic and may require frequent hospitalizations for stabilization. We should not disallow or misdirect those patients who need inpatient care from receiving such because of an arbitrary incentive to reduce rehospitalizations out of fear of punitive financial damages. The unforeseen risks here are real.”

Dr. Yancy says studies based on CMS data have found that institutions with higher readmission rates have lower 30-day mortality rates.² He cautions hospitalists to be “very thoughtful about an overzealous embrace of reducing all readmissions for heart failure.” Instead, the goal should be to limit the “avoidable readmissions.”

“And for the patient that clearly has advanced disease,” he says, “rather than triaging them away from the hospital, we really should be very respectful of their disease. Keep those patients where disease-modifying interventions can be deployed, and we can work to achieve the best possible outcome for those that have the most advanced disease.”

3) New interventional technologies will mean more complex patients, so be ready.

Advances in interventional procedures, including transcatheter aortic valve replacement (TAVR) and endoscopic mitral valve repair, will translate into a new population of highly complex patients. Many of these patients will be in their 80s or 90s.

“It’s a whole new paradigm shift of technology,” says John Harold, MD, president-elect of the American College of Cardiology and past chief of staff and department of medicine clinical chief of staff at Cedars-Sinai Medical Center in Los Angeles. “Very often, the hospitalist is at the front dealing with all of these issues.”

Many of these patients have other problems, including renal insufficiency, diabetes, and the like.

“They have all sorts of other things going on simultaneously, so very often the hospitalist becomes … the point person in dealing with all of these issues,” Dr. Harold says.

4) Aldosterone antagonists, though probably underutilized, can be very effective but require caution.

Aldosterone antagonists can greatly improve outcomes and reduce hospitalization in heart-failure patients, but they have to be used with very careful dosing and patient selection, Dr. Fonarow says. And they require early follow-up once patients are discharged.

“Only about a third of ideal candidates with heart failure are currently treated with this agent, even though it markedly improves outcome and is Class I-recommended in the guidelines,” Dr. Fonarow says. “But this is one where it needs to be started at appropriate low doses, with meticulous monitoring in both the inpatient and the outpatient setting, early follow-up, and early laboratory checks.”

5) Switching from IV diuretics to an oral regimen calls for careful monitoring.

Transitioning patients from IV diuretics to oral regimens is an area rife with mistakes, Dr. Fonarow says. It requires a lot of “meticulous attention to proper potassium supplementation and monitoring of renal function and electrolyte levels,” he says.

Medication reconciliation—“med rec”—is especially important during the transition from inpatient to outpatient.

“There are common medication errors that are made during this transition,” Dr. Fonarow says. “Hospitalists, along with other [care team] members, can really play a critically important role in trying to reduce that risk.”

6) Patients with heart failure with preserved ejection

fraction have outcomes over the longer haul similar to those with heart failure with reduced ejection fraction. And in preserved ejection fraction cases, the contributing illnesses must be addressed.

“We really can’t exercise a thought economy that just says, ‘Extrapolate the evidence-based therapies for heart failure with reduced ejection fraction to heart failure with preserved ejection fraction’ and expect good outcomes,” Dr. Yancy says. “That’s not the case. We don’t have an evidence base to substantiate that.”

He says one or more common comorbidities (e.g. atrial fibrillation, hypertension, obesity, diabetes, renal insufficiency) are present in 90% of patients with preserved ejection fraction. Treatment of those comorbidities—for example, rate control in afib patients, lowering the blood pressure in hypertension patients—has to be done with care.

“We should recognize that the therapy for this condition, albeit absent any specifically indicated interventions that will change its natural history, can still be skillfully constructed,” Dr. Yancy says. “But that construct needs to reflect the recommended, guideline-driven interventions for the concomitant other comorbidities.”

7) Inotropic agents can do more harm than good.

For patients who aren’t in cardiogenic shock, using inotropic agents doesn’t help. In fact, it might actually hurt. Dr. Fonarow says studies have shown these agents can “prolong length of stay, cause complications, and increase mortality risk.”

He notes that the use of inotropes should be avoided, or if it’s being considered, a cardiologist with knowledge and experience in heart failure should be involved in the treatment and care.

Statements about avoiding inotropes in heart failure, except under very specific circumstances, have been “incredibly strengthened” recently in the American College of Cardiology and Heart Failure Society of America guidelines.³

8) Pay attention to the ins and outs of new antiplatelet therapies.

For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event. There’s no simple antidote.

—John Harold, MD, president-elect, American College of Cardiology, former chief of staff, department of medicine, Cedars-Sinai Medical Center, Los Angeles

Hospitalists caring for acute coronary syndrome patients need to familiarize themselves with updated guidelines and additional therapies that are now available, Dr. Fonarow says. New antiplatelet therapies (e.g. prasugrel and ticagrelor) are available as part of the armamentarium, along with the mainstay clopidogrel.

“These therapies lower the risk of recurrent events, lowered the risk of stent thrombosis,” he says. “In the case of ticagrelor, it actually lowered all-cause mortality. These are important new therapies, with new guideline recommendations, that all hospitalists should be aware of.”

9) Bridging anticoagulant therapy in patients going for electrophysiology procedures should be done only some, not most, of the time.

“Patients getting such devices as pacemakers or implantable cardioverter defribrillators (ICD) installed tend not to need bridging,” says Joaquin Cigarroa, MD, clinical chief of cardiology at Oregon Health & Science University in Portland.

He says it’s actually “safer” to do the procedure when patients “are on oral antithrombotics than switching them from an oral agent, and bridging with low- molecular-weight- or unfractionated heparin.”

“It’s a big deal,” Dr. Cigarroa adds, because it is risky to have elderly and frail patients on multiple antithrombotics. “Hemorrhagic complications in cardiology patients still occurs very frequently, so really be attuned to estimating bleeding risk and making sure that we’re dosing antithrombotics appropriately. Bridging should be the minority of patients, not the majority of patients.”

10) Some non-STEMI patients might benefit from getting to the catheterization lab quickly.

Door-to-balloon time is recognized as critical for ST-segment elevation myocardial infarction (STEMI) patients, but more recent work—such as in the TIMACS trial—finds benefits of early revascularization for some non-STEMI patients as well.²

“This trial showed that among higher-risk patients, using a validated risk score, that those patients did benefit from an early approach, meaning going to the cath lab in the first 12 hours of hospitalization,” Dr. Fonarow says. “We now have more information about the optimal timing of coronary angiography and potential revascularization of higher-risk patients with non-ST-segment elevation MI.”

11) Beware the idiosyncrasies of new anticoagulants.

The introduction of dabigatran and rivaroxaban (and, perhaps soon, apixaban) to the array of anticoagulant therapies brings a new slate of considerations for hospitalists, Dr. Harold says.

“For the majority of these, there’s no specific way to reverse the anticoagulant effect in the event of a major bleeding event,” he says. “There’s no simple antidote. And the effect can last up to 12 to 24 hours, depending on the renal function. This is what the hospitalist will be called to deal with: bleeding complications in patients who have these newer anticoagulants on board.”

Dr. Fonarow says that the new CHA2DS2-VASc score has been found to do a better job than the traditional CHADS2 score in assessing afib stroke risk.⁴

12) Be cognizant of stent thrombosis and how to manage it.

Dr. Harold says that most hospitalists probably are up to date on drug-eluting stents and the risk of stopping dual antiplatelet therapy within several months of implant, but that doesn’t mean they won’t treat patients whose primary-care physicians (PCPs) aren’t up to date. He recommends working on these cases with hematologists.

“That knowledge is not widespread in terms of the internal-medicine community,” he says. “I’ve seen situations where patients have had their Plavix stopped for colonoscopies and they’ve had stent thrombosis. It’s this knowledge of cardiac patients who come in with recent deployment of drug-eluting stents who may end up having other issues.”

Tom Collins is a freelance writer in South Florida.

References

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119:1977-2016 an HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure. 2010;16(6):475-539.
2. Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? N Engl J Med. 2010;363:297-298.
3. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.
4. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107(6):1172-1179.
5. Associations between outpatient heart failure process-of-care measures and mortality. Circulation. 2011;123(15):1601-1610.

Larry Wellikson, MD, SFHM

I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.

Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.

In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.

Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.

Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.

Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?

Scalable Innovation

In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.¹

He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.

How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?

Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.

Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.

HM Takeaway

So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.

Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.

As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.

Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”

The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.

In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.

Dr. Wellikson is CEO of SHM.

Reference

1. Gawande A. The New Yorker. “Big Med.” The New Yorker website. Available at: http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande. Accessed Aug. 20, 2012.

Larry Wellikson, MD, SFHM

I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.

Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.

In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.

Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.

Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.

Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?

Scalable Innovation

In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.¹

He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.

How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?

Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.

Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.

HM Takeaway

So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.

Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.

As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.

Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”

The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.

In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.

Dr. Wellikson is CEO of SHM.

Reference

1. Gawande A. The New Yorker. “Big Med.” The New Yorker website. Available at: http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande. Accessed Aug. 20, 2012.

Larry Wellikson, MD, SFHM

I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.

Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.

In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.

Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.

Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.

Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?

Scalable Innovation

In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.¹

He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.

How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?

Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.

Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.

HM Takeaway

So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.

Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.

As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.

Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”

The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.

In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.

Dr. Wellikson is CEO of SHM.

Reference

1. Gawande A. The New Yorker. “Big Med.” The New Yorker website. Available at: http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande. Accessed Aug. 20, 2012.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

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.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

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.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

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.