HM16 Session Analysis: Health Information Technology Controversies

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HM16 Session Analysis: Health Information Technology Controversies

Presenter: Julie Hollberg, MD

Summary: Dr. Julie Hollberg, the chief medical information officer for Emory Healthcare, presented an overview of three pressing health information technology (IT) concerns at Hospital Medicine 2016, the “Year of the Hospitalist.” These issues are the use of copy-and-paste functions in electronic charting, alert fatigue, and patient access to electronic charts.

Dr. Hollberg states the key to leveraging healthcare IT to improve the patient and clinician experience is to coordinate people, technology, and the process. She relates that electronic note quality is poor due to lost narratives, “note bloat” (unnecessary text and data), and the use of copy-and-paste.

However, hospitalists themselves are essential in improving documentation. “We have 100% control of what goes into the note,” she describes. Some 90% of residents and attendings use copy-and-paste often. Most of the physicians agree the use of copy-and-paste increases inconsistencies, but 80% of physicians desire to continue the practice. The need for copy-and-paste should decrease as EMRs advance and expectations of note content is more broadly communicated.

Alerts are designed to improve patient safety and are a Meaningful Use initiative. The goal of clinical decision support is to provide the right information to the right person at the right time. However alert fatigue is a concern. Recommendations to address alert fatigue include making alerts non-interruptive, tier basing the alerts by severity, and decreasing the frequency of drug interaction alerts.

Dr. Hollberg also described the benefits of patient access to healthcare information on web portals. These benefits lead to improved patient engagement. Most physician concerns about open access has not been seen in actual practice. For example, only 1-8% of patients say that access to notes causes confusion, worry, or offense.

Key Takeaways:

  1. Use of copy-and-paste creates “note bloat” and inconsistencies. The practice is discouraged.
  2. Patients prefer access to healthcare information on portals. The benefit to improved access is greater patient engagement.
  3. While alert fatigue is a concern, clinicians should still read alerts! TH

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

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Presenter: Julie Hollberg, MD

Summary: Dr. Julie Hollberg, the chief medical information officer for Emory Healthcare, presented an overview of three pressing health information technology (IT) concerns at Hospital Medicine 2016, the “Year of the Hospitalist.” These issues are the use of copy-and-paste functions in electronic charting, alert fatigue, and patient access to electronic charts.

Dr. Hollberg states the key to leveraging healthcare IT to improve the patient and clinician experience is to coordinate people, technology, and the process. She relates that electronic note quality is poor due to lost narratives, “note bloat” (unnecessary text and data), and the use of copy-and-paste.

However, hospitalists themselves are essential in improving documentation. “We have 100% control of what goes into the note,” she describes. Some 90% of residents and attendings use copy-and-paste often. Most of the physicians agree the use of copy-and-paste increases inconsistencies, but 80% of physicians desire to continue the practice. The need for copy-and-paste should decrease as EMRs advance and expectations of note content is more broadly communicated.

Alerts are designed to improve patient safety and are a Meaningful Use initiative. The goal of clinical decision support is to provide the right information to the right person at the right time. However alert fatigue is a concern. Recommendations to address alert fatigue include making alerts non-interruptive, tier basing the alerts by severity, and decreasing the frequency of drug interaction alerts.

Dr. Hollberg also described the benefits of patient access to healthcare information on web portals. These benefits lead to improved patient engagement. Most physician concerns about open access has not been seen in actual practice. For example, only 1-8% of patients say that access to notes causes confusion, worry, or offense.

Key Takeaways:

  1. Use of copy-and-paste creates “note bloat” and inconsistencies. The practice is discouraged.
  2. Patients prefer access to healthcare information on portals. The benefit to improved access is greater patient engagement.
  3. While alert fatigue is a concern, clinicians should still read alerts! TH

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

Presenter: Julie Hollberg, MD

Summary: Dr. Julie Hollberg, the chief medical information officer for Emory Healthcare, presented an overview of three pressing health information technology (IT) concerns at Hospital Medicine 2016, the “Year of the Hospitalist.” These issues are the use of copy-and-paste functions in electronic charting, alert fatigue, and patient access to electronic charts.

Dr. Hollberg states the key to leveraging healthcare IT to improve the patient and clinician experience is to coordinate people, technology, and the process. She relates that electronic note quality is poor due to lost narratives, “note bloat” (unnecessary text and data), and the use of copy-and-paste.

However, hospitalists themselves are essential in improving documentation. “We have 100% control of what goes into the note,” she describes. Some 90% of residents and attendings use copy-and-paste often. Most of the physicians agree the use of copy-and-paste increases inconsistencies, but 80% of physicians desire to continue the practice. The need for copy-and-paste should decrease as EMRs advance and expectations of note content is more broadly communicated.

Alerts are designed to improve patient safety and are a Meaningful Use initiative. The goal of clinical decision support is to provide the right information to the right person at the right time. However alert fatigue is a concern. Recommendations to address alert fatigue include making alerts non-interruptive, tier basing the alerts by severity, and decreasing the frequency of drug interaction alerts.

Dr. Hollberg also described the benefits of patient access to healthcare information on web portals. These benefits lead to improved patient engagement. Most physician concerns about open access has not been seen in actual practice. For example, only 1-8% of patients say that access to notes causes confusion, worry, or offense.

Key Takeaways:

  1. Use of copy-and-paste creates “note bloat” and inconsistencies. The practice is discouraged.
  2. Patients prefer access to healthcare information on portals. The benefit to improved access is greater patient engagement.
  3. While alert fatigue is a concern, clinicians should still read alerts! TH

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

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HM16 Session Analysis: Lead Your Way to Success: Five Key Lessons for Hospitalists

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HM16 Session Analysis: Lead Your Way to Success: Five Key Lessons for Hospitalists

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

  1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
  2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
  3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
  4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
  5. Persuasion and influence. Six principles of persuasion are:

  1. Demonstrate trustworthiness and expertise.
  2. Social proof. Highlight existing norms or set new norms.
  3. Highlight similarities.
  4. A win-win situation with concessions shows willingness to participate.
  5. Reach agreement.
  6. An option that appears to be a rare offer is more desirable.

Key Takeaways

  • Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
  • Financial compensation can be detrimental to intrinsic motivation and worsen performance.
  • Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
  • Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
  • Social proof can be a powerful tool in persuasion.
  • The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

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

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Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

  1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
  2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
  3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
  4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
  5. Persuasion and influence. Six principles of persuasion are:

  1. Demonstrate trustworthiness and expertise.
  2. Social proof. Highlight existing norms or set new norms.
  3. Highlight similarities.
  4. A win-win situation with concessions shows willingness to participate.
  5. Reach agreement.
  6. An option that appears to be a rare offer is more desirable.

Key Takeaways

  • Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
  • Financial compensation can be detrimental to intrinsic motivation and worsen performance.
  • Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
  • Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
  • Social proof can be a powerful tool in persuasion.
  • The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

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

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

  1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
  2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
  3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
  4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
  5. Persuasion and influence. Six principles of persuasion are:

  1. Demonstrate trustworthiness and expertise.
  2. Social proof. Highlight existing norms or set new norms.
  3. Highlight similarities.
  4. A win-win situation with concessions shows willingness to participate.
  5. Reach agreement.
  6. An option that appears to be a rare offer is more desirable.

Key Takeaways

  • Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
  • Financial compensation can be detrimental to intrinsic motivation and worsen performance.
  • Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
  • Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
  • Social proof can be a powerful tool in persuasion.
  • The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

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

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U.S. Surgeon General Vivek Murthy, MD, MBA, Calls for Renewed Commitment to Public Health

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Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

  1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
  2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
  3. Focus on the mind and spirit, not just the body.
  4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

  1. Can a hospitalist leverage leadership to create a culture of healing?
  2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
  3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

  1. Hospitalists can be major supporters of public health and disease prevention; and
  2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.
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Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

  1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
  2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
  3. Focus on the mind and spirit, not just the body.
  4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

  1. Can a hospitalist leverage leadership to create a culture of healing?
  2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
  3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

  1. Hospitalists can be major supporters of public health and disease prevention; and
  2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.

Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

  1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
  2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
  3. Focus on the mind and spirit, not just the body.
  4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

  1. Can a hospitalist leverage leadership to create a culture of healing?
  2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
  3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

  1. Hospitalists can be major supporters of public health and disease prevention; and
  2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.
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Negotiation Skills for Physicians

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Negotiation Skills for Physicians

Summary

Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) learning about the true ZOPA in advance and b) determining how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. Addressing the specific reason a person is not willing to change from the status quo enables progress.

While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaway

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement, as well as your reservation value.
  2. Understand your zone of possible agreement, and be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist you in reaching an agreement.

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Summary

Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) learning about the true ZOPA in advance and b) determining how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. Addressing the specific reason a person is not willing to change from the status quo enables progress.

While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaway

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement, as well as your reservation value.
  2. Understand your zone of possible agreement, and be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist you in reaching an agreement.

Summary

Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) learning about the true ZOPA in advance and b) determining how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. Addressing the specific reason a person is not willing to change from the status quo enables progress.

While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaway

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement, as well as your reservation value.
  2. Understand your zone of possible agreement, and be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist you in reaching an agreement.

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Hospitalist Program Building Blocks

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Hospitalist Program Building Blocks

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

  • Establish the rationale for the program and include all stakeholders;
  • Determine financial expectations;
  • Define scope of practice;
  • Organize nursing and referral physician collaboration;
  • Assess staffing and workload expectations;
  • Establish referral base; and
  • Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

  • Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
  • Newborn medicine care;
  • Internal group clinical practice guidelines;
  • Co-management of surgical or specialty patients;
  • Transfers from other hospitals or continuing care from tertiary care centers;
  • Pediatric code teams and rapid response teams;
  • Advanced code and emergency preparedness and mock code training; and
  • Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaway

  1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
  2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
  3. After a program is established and fundamentals are in place, other important advance practices can be added. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
  4. For a multiple site or distributed program, high level collaboration and transparency are essential.

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Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

  • Establish the rationale for the program and include all stakeholders;
  • Determine financial expectations;
  • Define scope of practice;
  • Organize nursing and referral physician collaboration;
  • Assess staffing and workload expectations;
  • Establish referral base; and
  • Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

  • Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
  • Newborn medicine care;
  • Internal group clinical practice guidelines;
  • Co-management of surgical or specialty patients;
  • Transfers from other hospitals or continuing care from tertiary care centers;
  • Pediatric code teams and rapid response teams;
  • Advanced code and emergency preparedness and mock code training; and
  • Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaway

  1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
  2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
  3. After a program is established and fundamentals are in place, other important advance practices can be added. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
  4. For a multiple site or distributed program, high level collaboration and transparency are essential.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

  • Establish the rationale for the program and include all stakeholders;
  • Determine financial expectations;
  • Define scope of practice;
  • Organize nursing and referral physician collaboration;
  • Assess staffing and workload expectations;
  • Establish referral base; and
  • Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

  • Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
  • Newborn medicine care;
  • Internal group clinical practice guidelines;
  • Co-management of surgical or specialty patients;
  • Transfers from other hospitals or continuing care from tertiary care centers;
  • Pediatric code teams and rapid response teams;
  • Advanced code and emergency preparedness and mock code training; and
  • Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaway

  1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
  2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
  3. After a program is established and fundamentals are in place, other important advance practices can be added. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
  4. For a multiple site or distributed program, high level collaboration and transparency are essential.

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Pediatric Hospital Medicine 2014: Negotiation 101

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Pediatric Hospital Medicine 2014: Negotiation 101

Presenter

Vincent Chiang, MD, Harvard Medical School and Boston Children's Hospital

Summary


Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing for and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) the need to learn about the true ZOPA in advance; and b) how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. By addressing the specific reason a person is not willing to change from the status quo, progress can be made.


While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaways

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement and reservation value.
  2. Understand your zone of possible agreement and then be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist in reaching agreement. TH

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

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Presenter

Vincent Chiang, MD, Harvard Medical School and Boston Children's Hospital

Summary


Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing for and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) the need to learn about the true ZOPA in advance; and b) how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. By addressing the specific reason a person is not willing to change from the status quo, progress can be made.


While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaways

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement and reservation value.
  2. Understand your zone of possible agreement and then be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist in reaching agreement. TH

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

Presenter

Vincent Chiang, MD, Harvard Medical School and Boston Children's Hospital

Summary


Physicians suffer from “arrested development,” said Dr. Chiang, a hospitalist and chief of inpatient services at Boston Children’s Hospital, during a PHM2014 workshop on the basics of negotiation. Dr. Chiang was referring to the fact that in several professional realms, including negotiation, most physicians have not had the traditional experience of interviewing for and negotiating for jobs after high school or college.

An understanding of several negotiation concepts can help the negotiator achieve an agreeable solution. Awareness of values and limits prior to the actual discussion or negotiation will increase the chance of a successful negotiation. Examples of some of these concepts are:

  1. Best alternative to a negotiation agreement (BATNA). This is the course of action if negotiations fail. The negotiator should not accept a worse resolution than the BATNA.
  2. Reservation value (RV). This is the lowest value a negotiator will accept in a deal.
  3. Zone of possible agreement (ZOPA). This is the intellectual zone between two parties in a negotiation where an agreement can be reached.

The twin tasks of negotiation are a) the need to learn about the true ZOPA in advance; and b) how to influence the other person’s perception of this zone.

There are several negotiation methods and strategies of influence that can be used to support your position or goals. For example, status quo bias is very common. By addressing the specific reason a person is not willing to change from the status quo, progress can be made.


While it is important to advocate for one’s position, fairness is an important variable in reaching an agreement. Fairness often is not universally defined. Communication is essential in understanding each group’s position.

Key Takeaways

  1. Before entering a negotiation, understand your best alternative to a negotiation agreement and reservation value.
  2. Understand your zone of possible agreement and then be aware of the zone of possible agreement of the person you are working with.
  3. Learn strategies of influence to assist negotiations.
  4. Fairness will assist in reaching agreement. TH

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

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Pediatric Hospital Medicine 2014: Building Blocks in the Evolution of a Successful Distributed Hospitalist Program

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Pediatric Hospital Medicine 2014: Building Blocks in the Evolution of a Successful Distributed Hospitalist Program

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

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

Issue
The Hospitalist - 2014(07)
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Topics
Sections

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

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

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

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

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HM14 Special Report: Creation of a Pediatric Hospital Medicine Dashboard Across a Four Hospital Network

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HM14 Special Report: Creation of a Pediatric Hospital Medicine Dashboard Across a Four Hospital Network

Presenter: Lindsay Fox, MD

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

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

Takeaways:

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

• A dashboard can effect change by engaging individual hospitalists.

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

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

 

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The Hospitalist - 2014(03)
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Presenter: Lindsay Fox, MD

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

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

Takeaways:

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

• A dashboard can effect change by engaging individual hospitalists.

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

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

 

Presenter: Lindsay Fox, MD

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

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

Takeaways:

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

• A dashboard can effect change by engaging individual hospitalists.

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

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

 

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HM14 Special Report: The Future of the Healthcare Marketplace

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HM14 Special Report: The Future of the Healthcare Marketplace

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

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

Dr. Morrison described several key current issues, including:

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

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

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

4. Pressure on costs and delivering value is intensifying;

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

6. There is a renewed focus on primary care.

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

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

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

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

He envisions four scenarios for the exchanges:

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

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

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

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

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

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

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

 

 

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

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

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

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

Key points:

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

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

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

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

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

Issue
The Hospitalist - 2014(03)
Publications
Sections

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

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

Dr. Morrison described several key current issues, including:

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

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

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

4. Pressure on costs and delivering value is intensifying;

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

6. There is a renewed focus on primary care.

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

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

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

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

He envisions four scenarios for the exchanges:

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

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

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

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

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

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

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

 

 

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

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

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

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

Key points:

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

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

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

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

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

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

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

Dr. Morrison described several key current issues, including:

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

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

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

4. Pressure on costs and delivering value is intensifying;

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

6. There is a renewed focus on primary care.

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

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

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

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

He envisions four scenarios for the exchanges:

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

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

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

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

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

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

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

 

 

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

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

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

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

Key points:

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

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

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

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

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

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HM14 Special Report: Rationale and Review of the New Guidelines for First Febrile UTI

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HM14 Special Report: Rationale and Review of the New Guidelines for First Febrile UTI

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

  • Risk of having infection
  • Making a diagnosis
  • Treatment of UTI
  • Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

  1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
  2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
  3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
  4. Oral and parenteral routes are equally efficacious.
  5. The clinician should choose 7-14 days as duration of treatment.
  6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
  7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

  • Understand the evidence and limitations used for all clinical guidelines that you use in practice.
  • The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
  •  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

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

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

 

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Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

  • Risk of having infection
  • Making a diagnosis
  • Treatment of UTI
  • Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

  1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
  2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
  3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
  4. Oral and parenteral routes are equally efficacious.
  5. The clinician should choose 7-14 days as duration of treatment.
  6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
  7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

  • Understand the evidence and limitations used for all clinical guidelines that you use in practice.
  • The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
  •  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

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

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

 

Presenter: Maria Finnell, M.D., a leading member of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection

Summary: Dr. Finnell summarized the recent changes in diagnosis and management of pediatric urinary tract infections (UTIs). The 2011 publication of “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months” was an update of the 1999 technical report of UTI management. Dr. Finnell reviewed the difference between evidence based and eminence based recommendations. She stated the term “recommendations” was changed to “key action statements” in a new explicit reporting format. Aggregate quality of the evidence is presented in the report in an effort to keep statements transparent.

The process of updating the new guideline was based on the U.S. Preventive Services Task Force approach using a stepwise process. For the revised UTI recommendations the steps were narrowed to:

  • Risk of having infection
  • Making a diagnosis
  • Treatment of UTI
  • Identification and Evaluation for high risk conditions

Patient population for this guideline includes initial UTI in child age 2 months to 2 years of age. Patients with neurological conditions or recurrent UTI or renal damage are excluded. Dr. Finnell reviewed action statements for the revised guidelines. A summary of some of these statements:

  1. If antibiotics are going to be administered, a urine specimen should be collected by catheterization or suprapubic aspiration (SPA).
  2. Assessment of UTI risk should be performed in a febrile child with no source of infection. The guideline cites specific data for risk. If the likelihood is low then it is reasonable to follow the child clinically without a urine specimen. If the likelihood of a UTI is high then a urine specimen should be obtained.
  3. To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA.
  4. Oral and parenteral routes are equally efficacious.
  5. The clinician should choose 7-14 days as duration of treatment.
  6. Febrile infants with UTIs should undergo renal and bladder ultrasonography.
  7. VCUG should not be routinely performed after first UTI if ultrasound is normal.

Dr. Finnell also discussed controversy of not performing a VCUG after a first febrile UTI, as was recommended in the 1999 technical report. She summarized that about 100 children would need to undergo one UTI in the first year. She also reviewed limitations of any guidelines. New studies will assist in monitoring population changes with the revised guideline.

Key Takeaways:

  • Understand the evidence and limitations used for all clinical guidelines that you use in practice.
  • The updated 2011 guideline for evaluation and management of first febrile UTIs uses risk stratification as an initial approach.
  •  A major change in the updated 2011 guideline for evaluation and management of first febrile UTIs is that a VCUG is not required for initial evaluation.

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

Reference:

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3).

 

 

 

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