Certification on Our Minds

I was wondering whether and when hospital medicine might become a board certification and distinct subspecialty?

Susan Pereira, MD

Vallejo, Calif.

Dr. Hospitalist responds: This is a question on many minds nowadays. With fewer primary care doctors providing inpatient care, new hospitalist programs are popping up all over.

Approximately 85% of this country’s more than 20,000 hospitalists are general internists. For that reason, we are seeing a divergence in the career pathways of these physicians. Some consider themselves outpatient providers; others want to offer only inpatient care. Should we call general internists who just provide inpatient care “inpatient care specialists”? The answer depends on whom you ask.

Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), holder of the Lynne and Marc Benioff Endowed Chair in Hospital Medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service at UCSF Medical Center, past president of SHM, member of the American Board of Internal Medicine (ABIM) board of directors, and author of “Wachter’s World” (www.wachtersworld. com) coined the term “hospitalist.” Early in the movement, he and other leaders worried that identifying individuals who worked as hospitalists would hinder the growth of hospital medicine because it would allow payers to exclude primary care providers from practicing in the hospital. Clearly that has not occurred, and the field continues to grow.

Four years ago, the SHM Board of Directors began to look at this issue of hospitalist certification. Mary Jo Gorman, MD, past president of SHM, said certifying hospitalists would allow patients, payers, and hospitals to recognize the quality of work these physicians provide. Later in 2004, the SHM Board of Directors approved a resolution outlining the need to recognize hospitalists as unique providers, and began developing a process for formally certifying hospital medicine.

In 2006, ABIM, a governing board that sets the standards and certifies the knowledge, skills, and aptitudes of U.S. physicians who practice internal medicine and its subspecialties, announced it would create a Recognition of Focused Practice (RFP) for Hospital Medicine, as part of its Maintenance of Certification (MOC) process.

The exact criteria aren’t yet finalized, but ABIM President and Chief Executive Officer Christine K. Cassel, MD, said they likely will include “a combination of significant practice focus in hospital medicine, a high knowledge level of modern, evidence-based hospital care, and a demonstrated commitment to continuously improving the quality of hospital care.”

“ABIM looks forward to working with experts in hospital medicine to develop a process and standards for recognition of this important discipline,” she says.

In my opinion, the SHM/ABIM pairing is wise for several reasons. Partnership with an established organization brings credibility to the process and speeds eventual acceptance of certification. Also, ABIM is the logical choice to start because so many hospitalists are internists. This does not, however, preclude working with the American Board of Pediatrics, the American Board of Family Medicine, or any other certifying organization. In fact, a successful SHM/ABIM partnership could establish a framework for others to follow.

One thing to keep in mind: Dr. Wachter has stressed the fact that ABIM is recognizing an area of focused practice—not expertise. Certification is not the same as fellowship. Nobody is suggesting hospitalists need fellowship training to do their jobs.

What about general internists who practice outpatient medicine? In 2007, ABIM proposed a Comprehensive Care Internal Medicine (CCIM) credential for office-based general internists. This would differentiate internists in the office setting who provide ongoing, coordinated care for a panel of patients from internists who work in urgent care or academic, administrative, or research settings.

The American College of Physicians (ACP) expressed concern about the CCIM credential, saying it would burden physicians and hurt primary care outreach efforts. “CCIM may pose another burdensome hoop that adds time, expense, and limited value, leading to fewer students choosing careers in, and fewer physicians practicing, office-based internal medicine,” wrote ACP in a review of the proposal. More work will be necessary before the larger medical community will accept the CCIM credential.

Meanwhile, the ABIM continues to move forward with the RFP in hospital medicine. For example, Jeff Wiese, MD, professor of medicine at Tulane University in New Orleans and member of SHM’s Board of Directors, became chair of the hospital medicine MOC examination committee, which aims to add hospital medicine-specific elements to the MOC process. If this rapid pace continues, it is realistic to expect examinees to sit for the first tests in 2010.

In the past, Dr. Wachter has raised important questions about this RFP. Will anybody choose to get certified in hospital medicine? What effect will it have on primary care? How will the market value this certification? Will certified hospitalists get paid more? What will happen to those who aren’t certified? Is this the start of a separate specialty with separate training?

I believe when the time comes, hospitalists will choose to get certified. They will view this as a way to distinguish themselves from physicians who work as hospitalists for one to two years between residency and fellowship. Right now, job opportunities for hospitalists abound, but at some point the market will become saturated. The more saturated the market, the greater the value of hospitalist certification. Employers will use this RFP to separate qualified candidates. I also believe it will prevent the remaining primary care physicians from providing care in the hospital. Without additional external funding, however, I doubt this will lead to separate hospitalist training. TH

Certification on Our Minds

I was wondering whether and when hospital medicine might become a board certification and distinct subspecialty?

Susan Pereira, MD

Vallejo, Calif.

Dr. Hospitalist responds: This is a question on many minds nowadays. With fewer primary care doctors providing inpatient care, new hospitalist programs are popping up all over.

Approximately 85% of this country’s more than 20,000 hospitalists are general internists. For that reason, we are seeing a divergence in the career pathways of these physicians. Some consider themselves outpatient providers; others want to offer only inpatient care. Should we call general internists who just provide inpatient care “inpatient care specialists”? The answer depends on whom you ask.

Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), holder of the Lynne and Marc Benioff Endowed Chair in Hospital Medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service at UCSF Medical Center, past president of SHM, member of the American Board of Internal Medicine (ABIM) board of directors, and author of “Wachter’s World” (www.wachtersworld. com) coined the term “hospitalist.” Early in the movement, he and other leaders worried that identifying individuals who worked as hospitalists would hinder the growth of hospital medicine because it would allow payers to exclude primary care providers from practicing in the hospital. Clearly that has not occurred, and the field continues to grow.

Four years ago, the SHM Board of Directors began to look at this issue of hospitalist certification. Mary Jo Gorman, MD, past president of SHM, said certifying hospitalists would allow patients, payers, and hospitals to recognize the quality of work these physicians provide. Later in 2004, the SHM Board of Directors approved a resolution outlining the need to recognize hospitalists as unique providers, and began developing a process for formally certifying hospital medicine.

In 2006, ABIM, a governing board that sets the standards and certifies the knowledge, skills, and aptitudes of U.S. physicians who practice internal medicine and its subspecialties, announced it would create a Recognition of Focused Practice (RFP) for Hospital Medicine, as part of its Maintenance of Certification (MOC) process.

The exact criteria aren’t yet finalized, but ABIM President and Chief Executive Officer Christine K. Cassel, MD, said they likely will include “a combination of significant practice focus in hospital medicine, a high knowledge level of modern, evidence-based hospital care, and a demonstrated commitment to continuously improving the quality of hospital care.”

“ABIM looks forward to working with experts in hospital medicine to develop a process and standards for recognition of this important discipline,” she says.

In my opinion, the SHM/ABIM pairing is wise for several reasons. Partnership with an established organization brings credibility to the process and speeds eventual acceptance of certification. Also, ABIM is the logical choice to start because so many hospitalists are internists. This does not, however, preclude working with the American Board of Pediatrics, the American Board of Family Medicine, or any other certifying organization. In fact, a successful SHM/ABIM partnership could establish a framework for others to follow.

One thing to keep in mind: Dr. Wachter has stressed the fact that ABIM is recognizing an area of focused practice—not expertise. Certification is not the same as fellowship. Nobody is suggesting hospitalists need fellowship training to do their jobs.

What about general internists who practice outpatient medicine? In 2007, ABIM proposed a Comprehensive Care Internal Medicine (CCIM) credential for office-based general internists. This would differentiate internists in the office setting who provide ongoing, coordinated care for a panel of patients from internists who work in urgent care or academic, administrative, or research settings.

The American College of Physicians (ACP) expressed concern about the CCIM credential, saying it would burden physicians and hurt primary care outreach efforts. “CCIM may pose another burdensome hoop that adds time, expense, and limited value, leading to fewer students choosing careers in, and fewer physicians practicing, office-based internal medicine,” wrote ACP in a review of the proposal. More work will be necessary before the larger medical community will accept the CCIM credential.

Meanwhile, the ABIM continues to move forward with the RFP in hospital medicine. For example, Jeff Wiese, MD, professor of medicine at Tulane University in New Orleans and member of SHM’s Board of Directors, became chair of the hospital medicine MOC examination committee, which aims to add hospital medicine-specific elements to the MOC process. If this rapid pace continues, it is realistic to expect examinees to sit for the first tests in 2010.

In the past, Dr. Wachter has raised important questions about this RFP. Will anybody choose to get certified in hospital medicine? What effect will it have on primary care? How will the market value this certification? Will certified hospitalists get paid more? What will happen to those who aren’t certified? Is this the start of a separate specialty with separate training?

I believe when the time comes, hospitalists will choose to get certified. They will view this as a way to distinguish themselves from physicians who work as hospitalists for one to two years between residency and fellowship. Right now, job opportunities for hospitalists abound, but at some point the market will become saturated. The more saturated the market, the greater the value of hospitalist certification. Employers will use this RFP to separate qualified candidates. I also believe it will prevent the remaining primary care physicians from providing care in the hospital. Without additional external funding, however, I doubt this will lead to separate hospitalist training. TH

Certification on Our Minds

I was wondering whether and when hospital medicine might become a board certification and distinct subspecialty?

Susan Pereira, MD

Vallejo, Calif.

Dr. Hospitalist responds: This is a question on many minds nowadays. With fewer primary care doctors providing inpatient care, new hospitalist programs are popping up all over.

Approximately 85% of this country’s more than 20,000 hospitalists are general internists. For that reason, we are seeing a divergence in the career pathways of these physicians. Some consider themselves outpatient providers; others want to offer only inpatient care. Should we call general internists who just provide inpatient care “inpatient care specialists”? The answer depends on whom you ask.

Robert M. Wachter, MD, professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), holder of the Lynne and Marc Benioff Endowed Chair in Hospital Medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service at UCSF Medical Center, past president of SHM, member of the American Board of Internal Medicine (ABIM) board of directors, and author of “Wachter’s World” (www.wachtersworld. com) coined the term “hospitalist.” Early in the movement, he and other leaders worried that identifying individuals who worked as hospitalists would hinder the growth of hospital medicine because it would allow payers to exclude primary care providers from practicing in the hospital. Clearly that has not occurred, and the field continues to grow.

Four years ago, the SHM Board of Directors began to look at this issue of hospitalist certification. Mary Jo Gorman, MD, past president of SHM, said certifying hospitalists would allow patients, payers, and hospitals to recognize the quality of work these physicians provide. Later in 2004, the SHM Board of Directors approved a resolution outlining the need to recognize hospitalists as unique providers, and began developing a process for formally certifying hospital medicine.

In 2006, ABIM, a governing board that sets the standards and certifies the knowledge, skills, and aptitudes of U.S. physicians who practice internal medicine and its subspecialties, announced it would create a Recognition of Focused Practice (RFP) for Hospital Medicine, as part of its Maintenance of Certification (MOC) process.

The exact criteria aren’t yet finalized, but ABIM President and Chief Executive Officer Christine K. Cassel, MD, said they likely will include “a combination of significant practice focus in hospital medicine, a high knowledge level of modern, evidence-based hospital care, and a demonstrated commitment to continuously improving the quality of hospital care.”

“ABIM looks forward to working with experts in hospital medicine to develop a process and standards for recognition of this important discipline,” she says.

In my opinion, the SHM/ABIM pairing is wise for several reasons. Partnership with an established organization brings credibility to the process and speeds eventual acceptance of certification. Also, ABIM is the logical choice to start because so many hospitalists are internists. This does not, however, preclude working with the American Board of Pediatrics, the American Board of Family Medicine, or any other certifying organization. In fact, a successful SHM/ABIM partnership could establish a framework for others to follow.

One thing to keep in mind: Dr. Wachter has stressed the fact that ABIM is recognizing an area of focused practice—not expertise. Certification is not the same as fellowship. Nobody is suggesting hospitalists need fellowship training to do their jobs.

What about general internists who practice outpatient medicine? In 2007, ABIM proposed a Comprehensive Care Internal Medicine (CCIM) credential for office-based general internists. This would differentiate internists in the office setting who provide ongoing, coordinated care for a panel of patients from internists who work in urgent care or academic, administrative, or research settings.

The American College of Physicians (ACP) expressed concern about the CCIM credential, saying it would burden physicians and hurt primary care outreach efforts. “CCIM may pose another burdensome hoop that adds time, expense, and limited value, leading to fewer students choosing careers in, and fewer physicians practicing, office-based internal medicine,” wrote ACP in a review of the proposal. More work will be necessary before the larger medical community will accept the CCIM credential.

Meanwhile, the ABIM continues to move forward with the RFP in hospital medicine. For example, Jeff Wiese, MD, professor of medicine at Tulane University in New Orleans and member of SHM’s Board of Directors, became chair of the hospital medicine MOC examination committee, which aims to add hospital medicine-specific elements to the MOC process. If this rapid pace continues, it is realistic to expect examinees to sit for the first tests in 2010.

In the past, Dr. Wachter has raised important questions about this RFP. Will anybody choose to get certified in hospital medicine? What effect will it have on primary care? How will the market value this certification? Will certified hospitalists get paid more? What will happen to those who aren’t certified? Is this the start of a separate specialty with separate training?

I believe when the time comes, hospitalists will choose to get certified. They will view this as a way to distinguish themselves from physicians who work as hospitalists for one to two years between residency and fellowship. Right now, job opportunities for hospitalists abound, but at some point the market will become saturated. The more saturated the market, the greater the value of hospitalist certification. Employers will use this RFP to separate qualified candidates. I also believe it will prevent the remaining primary care physicians from providing care in the hospital. Without additional external funding, however, I doubt this will lead to separate hospitalist training. TH

I’m convinced it is smart for many hospitalist practices to include nurse practitioners and/or physician assistants. The most common problem I see is that a practice doesn’t execute this idea well. They may have the right idea to add these providers, but they fail to create the right job description, support, and management oversight.

While there are a variety of terms in common use, such as “mid-level” and “allied health professional,” I will use “non-physician provider” (NPP) to refer to both NPs and PAs.

The two most common reasons to add NPPs are a strategy to manage growth in the difficult physician recruiting environment and as a way to optimize practice value (provide the best care at the lowest provider cost).

Valuable Roles?

My anecdotal experience suggests most practices have the NPP function in ways that may not be optimal. Most commonly, the NPP works much like another hospitalist in the practice, admitting and “carrying” their own patient caseload. There is often an attempt to have the NPP care for patients that are somewhat less sick and complicated, or care for a smaller patient volume (though this varies a lot).

This is a great concept, but often proves difficult to implement well. The NPPs in such practices often say their caseload—and amount of supervision and interaction with the physician hospitalists—varies a great deal, depending on which hospitalist is on duty. At times, they may have little interaction, leading to a defacto independent practice. At other times, work done by the NPP is repeated by the physician hospitalist. In either case, the NPP is unable to contribute optimally to the practice.

NPPs in this situation often express uncertainty about their job description and who serves as their physician supervisor. If the NPPs in your practice say their job varies, depending on which doctor is on duty, you’re probably limiting the NPP’s contribution to the practice.

Some practices have the NPP manage only the discharge process (and not provide ongoing patient care), including dictation of the discharge summary, for most or all hospitalist patients. In such a system, the NPP may have had little or no involvement with the patient prior to discharge. A variation on this system is to transfer a patient to the care of the NPP (with physician oversight) a day or two before the anticipated day of discharge and when the acute illness has improved.

While reasonable people can disagree, the problem I see with an NPP dedicated to managing the discharge process is that discharge is often the most complicated visit. Managing it well requires knowing a great deal about the patient’s medical and social situation. Asking any provider, including a physician, to step in on the last day and handle this, and prepare a meaningful discharge summary, is very challenging.

While that is unavoidable in some cases, it seems to me a poor idea to create a system in which it happens routinely for all (or nearly all) patients. I worry that referring doctors may not be pleased if they routinely get discharge summaries prepared by someone who had little or no involvement with the patient prior to the day of discharge. How informative and reliable could such a summary be?

New Alternatives

A few practices have begun asking NPPs to function in less common roles, but ones that may contribute more to the practice and provide the NPP with greater satisfaction.

A common scenario is for the several, day-shift doctors to end their work around 7 p.m. when they’re replaced by a single night doctor. And the number of admissions and “crosscover” burdens tend to be greatest in the late afternoon and early night hours around this shift change. This regularly overwhelms the night doctor for the first few hours of the shift (and the ED gets backed up, and so on).

Relief in the form of an NPP functioning in a “swing shift” role—working from the mid-afternoon until around midnight—may make more sense for some practices than having a physician hospitalist work this shift. The NPP would be responsible for admitting patients (all of whom would be seen by the in-house supervising MD that night) and functioning as the first responder for all “crosscover” issues. The practice could have an NPP work this shift seven days a week, and all other patient visits could be made by the MD hospitalists (i.e., the NPP would not have their own “service” of patients to round on daily).

An NPP could also be put in charge of a consult service, such as serving as the main hospitalist consultant on orthopedic patients that need medical consultants. In this role, the NPP would work nearly all his/her time on a single floor, such as the orthopedic floor, and get to know the orthopedic physicians and nursing staff well. This close communication and working relationship would make the NPP well accepted and effective. While physician oversight would still be required, the NPP would likely take mental ownership of issues, such as response times to consult requests, rates of VTE prophylaxis, perioperative beta-blocker use, etc. This could lead to a rewarding role for the NPP and might result in better clinical performance because it would be “owned” by a single person. It is easy to envision a role like this on other units, such as psychiatry or an in-hospital skilled nursing unit.

Lastly, the NPP might be asked to own issues, such as glycemic control or CMS core measure performance for all hospitalist patients (or all patients in the hospital). He or she might see all diabetic patients daily and adjust glycemic therapy as appropriate, but all of those patients would have a separate MD hospitalist see them daily to care for all other problems.

Room for Opinions

There aren’t much data to guide decisions about the right or best role for NPPs in hospitalist practice. For various reasons including local culture, some practices may function best without including NPPs. Yet, many, or most, practices should thoughtfully consider high value roles for NPPs. I think it is important to avoid a knee-jerk response of simply adding NPPs in the role of additional hospitalists, and instead considering less traditional or novel roles. That is just my opinion (informed by considerable experience with a lot of practices) and reasonable people can see it differently. I’m interested in hearing from anyone with an opinion about optimal NPP roles within hospitalist practices.

Next month I’ll offer comments on the economics of NPPs and thoughts about patient satisfaction with NPPs. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I’m convinced it is smart for many hospitalist practices to include nurse practitioners and/or physician assistants. The most common problem I see is that a practice doesn’t execute this idea well. They may have the right idea to add these providers, but they fail to create the right job description, support, and management oversight.

While there are a variety of terms in common use, such as “mid-level” and “allied health professional,” I will use “non-physician provider” (NPP) to refer to both NPs and PAs.

The two most common reasons to add NPPs are a strategy to manage growth in the difficult physician recruiting environment and as a way to optimize practice value (provide the best care at the lowest provider cost).

Valuable Roles?

My anecdotal experience suggests most practices have the NPP function in ways that may not be optimal. Most commonly, the NPP works much like another hospitalist in the practice, admitting and “carrying” their own patient caseload. There is often an attempt to have the NPP care for patients that are somewhat less sick and complicated, or care for a smaller patient volume (though this varies a lot).

This is a great concept, but often proves difficult to implement well. The NPPs in such practices often say their caseload—and amount of supervision and interaction with the physician hospitalists—varies a great deal, depending on which hospitalist is on duty. At times, they may have little interaction, leading to a defacto independent practice. At other times, work done by the NPP is repeated by the physician hospitalist. In either case, the NPP is unable to contribute optimally to the practice.

NPPs in this situation often express uncertainty about their job description and who serves as their physician supervisor. If the NPPs in your practice say their job varies, depending on which doctor is on duty, you’re probably limiting the NPP’s contribution to the practice.

Some practices have the NPP manage only the discharge process (and not provide ongoing patient care), including dictation of the discharge summary, for most or all hospitalist patients. In such a system, the NPP may have had little or no involvement with the patient prior to discharge. A variation on this system is to transfer a patient to the care of the NPP (with physician oversight) a day or two before the anticipated day of discharge and when the acute illness has improved.

While reasonable people can disagree, the problem I see with an NPP dedicated to managing the discharge process is that discharge is often the most complicated visit. Managing it well requires knowing a great deal about the patient’s medical and social situation. Asking any provider, including a physician, to step in on the last day and handle this, and prepare a meaningful discharge summary, is very challenging.

While that is unavoidable in some cases, it seems to me a poor idea to create a system in which it happens routinely for all (or nearly all) patients. I worry that referring doctors may not be pleased if they routinely get discharge summaries prepared by someone who had little or no involvement with the patient prior to the day of discharge. How informative and reliable could such a summary be?

New Alternatives

A few practices have begun asking NPPs to function in less common roles, but ones that may contribute more to the practice and provide the NPP with greater satisfaction.

A common scenario is for the several, day-shift doctors to end their work around 7 p.m. when they’re replaced by a single night doctor. And the number of admissions and “crosscover” burdens tend to be greatest in the late afternoon and early night hours around this shift change. This regularly overwhelms the night doctor for the first few hours of the shift (and the ED gets backed up, and so on).

Relief in the form of an NPP functioning in a “swing shift” role—working from the mid-afternoon until around midnight—may make more sense for some practices than having a physician hospitalist work this shift. The NPP would be responsible for admitting patients (all of whom would be seen by the in-house supervising MD that night) and functioning as the first responder for all “crosscover” issues. The practice could have an NPP work this shift seven days a week, and all other patient visits could be made by the MD hospitalists (i.e., the NPP would not have their own “service” of patients to round on daily).

An NPP could also be put in charge of a consult service, such as serving as the main hospitalist consultant on orthopedic patients that need medical consultants. In this role, the NPP would work nearly all his/her time on a single floor, such as the orthopedic floor, and get to know the orthopedic physicians and nursing staff well. This close communication and working relationship would make the NPP well accepted and effective. While physician oversight would still be required, the NPP would likely take mental ownership of issues, such as response times to consult requests, rates of VTE prophylaxis, perioperative beta-blocker use, etc. This could lead to a rewarding role for the NPP and might result in better clinical performance because it would be “owned” by a single person. It is easy to envision a role like this on other units, such as psychiatry or an in-hospital skilled nursing unit.

Lastly, the NPP might be asked to own issues, such as glycemic control or CMS core measure performance for all hospitalist patients (or all patients in the hospital). He or she might see all diabetic patients daily and adjust glycemic therapy as appropriate, but all of those patients would have a separate MD hospitalist see them daily to care for all other problems.

Room for Opinions

There aren’t much data to guide decisions about the right or best role for NPPs in hospitalist practice. For various reasons including local culture, some practices may function best without including NPPs. Yet, many, or most, practices should thoughtfully consider high value roles for NPPs. I think it is important to avoid a knee-jerk response of simply adding NPPs in the role of additional hospitalists, and instead considering less traditional or novel roles. That is just my opinion (informed by considerable experience with a lot of practices) and reasonable people can see it differently. I’m interested in hearing from anyone with an opinion about optimal NPP roles within hospitalist practices.

Next month I’ll offer comments on the economics of NPPs and thoughts about patient satisfaction with NPPs. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I’m convinced it is smart for many hospitalist practices to include nurse practitioners and/or physician assistants. The most common problem I see is that a practice doesn’t execute this idea well. They may have the right idea to add these providers, but they fail to create the right job description, support, and management oversight.

While there are a variety of terms in common use, such as “mid-level” and “allied health professional,” I will use “non-physician provider” (NPP) to refer to both NPs and PAs.

The two most common reasons to add NPPs are a strategy to manage growth in the difficult physician recruiting environment and as a way to optimize practice value (provide the best care at the lowest provider cost).

Valuable Roles?

My anecdotal experience suggests most practices have the NPP function in ways that may not be optimal. Most commonly, the NPP works much like another hospitalist in the practice, admitting and “carrying” their own patient caseload. There is often an attempt to have the NPP care for patients that are somewhat less sick and complicated, or care for a smaller patient volume (though this varies a lot).

This is a great concept, but often proves difficult to implement well. The NPPs in such practices often say their caseload—and amount of supervision and interaction with the physician hospitalists—varies a great deal, depending on which hospitalist is on duty. At times, they may have little interaction, leading to a defacto independent practice. At other times, work done by the NPP is repeated by the physician hospitalist. In either case, the NPP is unable to contribute optimally to the practice.

NPPs in this situation often express uncertainty about their job description and who serves as their physician supervisor. If the NPPs in your practice say their job varies, depending on which doctor is on duty, you’re probably limiting the NPP’s contribution to the practice.

Some practices have the NPP manage only the discharge process (and not provide ongoing patient care), including dictation of the discharge summary, for most or all hospitalist patients. In such a system, the NPP may have had little or no involvement with the patient prior to discharge. A variation on this system is to transfer a patient to the care of the NPP (with physician oversight) a day or two before the anticipated day of discharge and when the acute illness has improved.

While reasonable people can disagree, the problem I see with an NPP dedicated to managing the discharge process is that discharge is often the most complicated visit. Managing it well requires knowing a great deal about the patient’s medical and social situation. Asking any provider, including a physician, to step in on the last day and handle this, and prepare a meaningful discharge summary, is very challenging.

While that is unavoidable in some cases, it seems to me a poor idea to create a system in which it happens routinely for all (or nearly all) patients. I worry that referring doctors may not be pleased if they routinely get discharge summaries prepared by someone who had little or no involvement with the patient prior to the day of discharge. How informative and reliable could such a summary be?

New Alternatives

A few practices have begun asking NPPs to function in less common roles, but ones that may contribute more to the practice and provide the NPP with greater satisfaction.

A common scenario is for the several, day-shift doctors to end their work around 7 p.m. when they’re replaced by a single night doctor. And the number of admissions and “crosscover” burdens tend to be greatest in the late afternoon and early night hours around this shift change. This regularly overwhelms the night doctor for the first few hours of the shift (and the ED gets backed up, and so on).

Relief in the form of an NPP functioning in a “swing shift” role—working from the mid-afternoon until around midnight—may make more sense for some practices than having a physician hospitalist work this shift. The NPP would be responsible for admitting patients (all of whom would be seen by the in-house supervising MD that night) and functioning as the first responder for all “crosscover” issues. The practice could have an NPP work this shift seven days a week, and all other patient visits could be made by the MD hospitalists (i.e., the NPP would not have their own “service” of patients to round on daily).

An NPP could also be put in charge of a consult service, such as serving as the main hospitalist consultant on orthopedic patients that need medical consultants. In this role, the NPP would work nearly all his/her time on a single floor, such as the orthopedic floor, and get to know the orthopedic physicians and nursing staff well. This close communication and working relationship would make the NPP well accepted and effective. While physician oversight would still be required, the NPP would likely take mental ownership of issues, such as response times to consult requests, rates of VTE prophylaxis, perioperative beta-blocker use, etc. This could lead to a rewarding role for the NPP and might result in better clinical performance because it would be “owned” by a single person. It is easy to envision a role like this on other units, such as psychiatry or an in-hospital skilled nursing unit.

Lastly, the NPP might be asked to own issues, such as glycemic control or CMS core measure performance for all hospitalist patients (or all patients in the hospital). He or she might see all diabetic patients daily and adjust glycemic therapy as appropriate, but all of those patients would have a separate MD hospitalist see them daily to care for all other problems.

Room for Opinions

There aren’t much data to guide decisions about the right or best role for NPPs in hospitalist practice. For various reasons including local culture, some practices may function best without including NPPs. Yet, many, or most, practices should thoughtfully consider high value roles for NPPs. I think it is important to avoid a knee-jerk response of simply adding NPPs in the role of additional hospitalists, and instead considering less traditional or novel roles. That is just my opinion (informed by considerable experience with a lot of practices) and reasonable people can see it differently. I’m interested in hearing from anyone with an opinion about optimal NPP roles within hospitalist practices.

Next month I’ll offer comments on the economics of NPPs and thoughts about patient satisfaction with NPPs. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

Hospitalists have been concerned about the entire continuum of care from the early days of the hospital medicine movement. We have tried to look at the system of healthcare from the patients’ viewpoint, where an admission to the hospital is rare in the larger scheme of their healthcare and their interaction with a variety of physicians and health professionals.

Hospitalists will always need to rely on our professional relationships with surgeons and specialists, as well as with the primary care physicians (PCPs) who refer their patients for admission to the hospital and who partner with us to resume patient care at discharge.

With this fundamental backdrop, two interesting trends in the PCP world—the patient-centered medical home (PCMH) and PCPs’ use of performance measurements to drive referrals to hospitals and specialists—will have a profound effect on hospitalists, the patients we treat, and the systems of care in which we work.

PCMH and Hospitalists

For many years, the problems in primary care have been virtually ignored and dismissed by the insurance industry—and even by most of organized medicine. As if a light has suddenly been turned on, everyone now wants to “do something” to save primary care.

One of the latest “solutions’ is the PCMH. As we all know, ideas without funding are just ideas. It’s time to take note of PCMH. Why? Because insurance companies and Medicare are paying for a variety of pilot and demonstration projects to see how PCMH might play out in real-life interactions among patients and physicians.

The main new characteristics in the PCMH (as opposed to the traditional PCP) are a more robust information system and the commitment of personnel and organization within the PCP practice to allow proactive coordination of the patient’s care. The hope on the performance side is that patients will receive better care that will lead to better patient satisfaction and better outcomes. On the payment side, the PCP must receive significant monetary support to pay for the staff and equipment to coordinate and manage their patient’s journey through an increasingly complex series of tests, referrals, and treatments.

Accountability

SHM has tried to raise the issues of how the PCMH would relate to hospitalists at key junctures in the hospitalization continuum. Hopefully this will lead to a dialogue with the PCP community about how PCMH proposals would meet the goals of defining accountability and responsibility for the PCMH and for hospitalists. In turn this would lead to a better, safer system for our patients.

While discussions have specifically focused on the PCMH-hospitalist interface, many of the same tenets of accountability, responsibility, timeliness, and information transfer would apply to the PCMH-specialist interfaces.

Time of Admission

Accurate, timely information is crucial at the time of acute illness. It would be expected that at the time of the patient’s arrival at the hospital the following set of data elements would be available to the hospitalist (and/or emergency department physician or specialist). These elements are lifted directly from the joint SHM-ACP-SGIM Transitions of Care Consensus document from 2007 (available at www.hospitalmedicine.org): principle diagnosis and problem list; medication list (reconciliation), including over-the-counter and herbal products, allergies, and drug interactions; emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; test results/pending results; clearly identifies medical home and/or transferring coordinating physician/institution; patient’s cognitive status; advance directives, power of attorney, consent; planned interventions, durable medical equipment, wound care; and assessment of caregiver status.

Time of Discharge

While it is clear that the hospitalist is responsible for overseeing the patient’s care while hospitalized, it is essential for patients and their families to know who will be accountable at the time of discharge. SHM proposes that the PCMH:

• Assume the primary role of caring for the patient as of the time of discharge from the hospital;
• Provide a timely first post-discharge office visit consistent with the acute illness as documented in the discharge summary; and
• Ensure a handoff formally confirmed and documented by the hospitalist and PCMH.

The hospitalist should provide to the PCMH:

• An accurate and timely discharge summary; and
• The availability to the PCMH to answer questions about the hospitalization.

Further, discharge summaries should include:

• Primary and secondary diagnoses;
• Pertinent history and physical findings;
• Dates of hospitalization, treatment provided, brief hospital course;
• Results of procedures and abnormal laboratory tests;
• Recommendations of any subspecialty consultants;
• Information given to the patient and family;
• The patient’s condition or functional status at discharge;
• Reconciled discharge medication regimen, with reasons for any changes and indications for newly prescribed medications;
• Details of follow-up arrangements made;
• Specific follow-up needs, including appointments or procedures to be scheduled, and tests pending at the time of discharge; and
• Name and contact information of the responsible hospital physician.1

Other Considerations

Obviously other aspects of the PCMH-hospitalist relationship must be considered, including when the PCMH would like to be informed (or involved) during their patient’s hospitalization, as well as how to manage the handoff of responsibilities and information when the patient leaves the hospital but does not go directly home (e.g., when they are sent to a skilled nursing facility or rehabilitation center). If we continue to look at solutions from the patient’s and family’s points of view, we can come up with a workable solution.

Performance-driven Referral

Part of the result of the growth of the hospital medicine movement is that, increasingly, PCPs are not directly managing their patients for acute illnesses. That said, the PCP still has a significant role in determining whether their patients get the best care available—even if other physicians (e.g., hospitalists, surgeons, subspecialists) deliver the actual care.

We are just at the beginning of performance measurement and reporting. Today, PCPs and their patients can log on to www.hospitalcompare.hhs.gov and look at any hospital’s performance for pneumonia, acute coronary syndrome, and heart failure. The era of disease-specific and institution-specific—even physician-specific—reporting grows on a seemingly monthly basis.

Armed with this information, the PCP’s role shifts from managing the acute illnesses of their patients to understanding the report cards on their local hospitals and specialists and using this information to direct their patients to the hospitals and physicians who have the best outcomes. The expanding role of the PCP as the informed guide for their patients further will drive hospitals and all physicians who rely on referrals to improve their feedback and communication with PCPs.

We will begin to see that best-of-breed hospitals not only will have excellent clinical outcomes but will be pushed to have better patient-satisfaction and PCP-satisfaction scores. This is an opportunity for enlightened PCPs to use their medical background and hands-on understanding of local healthcare to be a vital resource to their patients.

By the same token, this is an opportunity for product differentiation for hospitals and their hospitalists to reshape a healthcare referral world traditionally built more on geography and familiarity than on information and performance, and replace it with strong communication and better outcomes. The best thing about this approach is the patient wins. TH

Dr. Wellikson is the CEO of SHM

Reference

1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-841.

Hospitalists have been concerned about the entire continuum of care from the early days of the hospital medicine movement. We have tried to look at the system of healthcare from the patients’ viewpoint, where an admission to the hospital is rare in the larger scheme of their healthcare and their interaction with a variety of physicians and health professionals.

Hospitalists will always need to rely on our professional relationships with surgeons and specialists, as well as with the primary care physicians (PCPs) who refer their patients for admission to the hospital and who partner with us to resume patient care at discharge.

With this fundamental backdrop, two interesting trends in the PCP world—the patient-centered medical home (PCMH) and PCPs’ use of performance measurements to drive referrals to hospitals and specialists—will have a profound effect on hospitalists, the patients we treat, and the systems of care in which we work.

PCMH and Hospitalists

For many years, the problems in primary care have been virtually ignored and dismissed by the insurance industry—and even by most of organized medicine. As if a light has suddenly been turned on, everyone now wants to “do something” to save primary care.

One of the latest “solutions’ is the PCMH. As we all know, ideas without funding are just ideas. It’s time to take note of PCMH. Why? Because insurance companies and Medicare are paying for a variety of pilot and demonstration projects to see how PCMH might play out in real-life interactions among patients and physicians.

The main new characteristics in the PCMH (as opposed to the traditional PCP) are a more robust information system and the commitment of personnel and organization within the PCP practice to allow proactive coordination of the patient’s care. The hope on the performance side is that patients will receive better care that will lead to better patient satisfaction and better outcomes. On the payment side, the PCP must receive significant monetary support to pay for the staff and equipment to coordinate and manage their patient’s journey through an increasingly complex series of tests, referrals, and treatments.

Accountability

SHM has tried to raise the issues of how the PCMH would relate to hospitalists at key junctures in the hospitalization continuum. Hopefully this will lead to a dialogue with the PCP community about how PCMH proposals would meet the goals of defining accountability and responsibility for the PCMH and for hospitalists. In turn this would lead to a better, safer system for our patients.

While discussions have specifically focused on the PCMH-hospitalist interface, many of the same tenets of accountability, responsibility, timeliness, and information transfer would apply to the PCMH-specialist interfaces.

Time of Admission

Accurate, timely information is crucial at the time of acute illness. It would be expected that at the time of the patient’s arrival at the hospital the following set of data elements would be available to the hospitalist (and/or emergency department physician or specialist). These elements are lifted directly from the joint SHM-ACP-SGIM Transitions of Care Consensus document from 2007 (available at www.hospitalmedicine.org): principle diagnosis and problem list; medication list (reconciliation), including over-the-counter and herbal products, allergies, and drug interactions; emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; test results/pending results; clearly identifies medical home and/or transferring coordinating physician/institution; patient’s cognitive status; advance directives, power of attorney, consent; planned interventions, durable medical equipment, wound care; and assessment of caregiver status.

Time of Discharge

While it is clear that the hospitalist is responsible for overseeing the patient’s care while hospitalized, it is essential for patients and their families to know who will be accountable at the time of discharge. SHM proposes that the PCMH:

• Assume the primary role of caring for the patient as of the time of discharge from the hospital;
• Provide a timely first post-discharge office visit consistent with the acute illness as documented in the discharge summary; and
• Ensure a handoff formally confirmed and documented by the hospitalist and PCMH.

The hospitalist should provide to the PCMH:

• An accurate and timely discharge summary; and
• The availability to the PCMH to answer questions about the hospitalization.

Further, discharge summaries should include:

• Primary and secondary diagnoses;
• Pertinent history and physical findings;
• Dates of hospitalization, treatment provided, brief hospital course;
• Results of procedures and abnormal laboratory tests;
• Recommendations of any subspecialty consultants;
• Information given to the patient and family;
• The patient’s condition or functional status at discharge;
• Reconciled discharge medication regimen, with reasons for any changes and indications for newly prescribed medications;
• Details of follow-up arrangements made;
• Specific follow-up needs, including appointments or procedures to be scheduled, and tests pending at the time of discharge; and
• Name and contact information of the responsible hospital physician.1

Other Considerations

Obviously other aspects of the PCMH-hospitalist relationship must be considered, including when the PCMH would like to be informed (or involved) during their patient’s hospitalization, as well as how to manage the handoff of responsibilities and information when the patient leaves the hospital but does not go directly home (e.g., when they are sent to a skilled nursing facility or rehabilitation center). If we continue to look at solutions from the patient’s and family’s points of view, we can come up with a workable solution.

Performance-driven Referral

Part of the result of the growth of the hospital medicine movement is that, increasingly, PCPs are not directly managing their patients for acute illnesses. That said, the PCP still has a significant role in determining whether their patients get the best care available—even if other physicians (e.g., hospitalists, surgeons, subspecialists) deliver the actual care.

We are just at the beginning of performance measurement and reporting. Today, PCPs and their patients can log on to www.hospitalcompare.hhs.gov and look at any hospital’s performance for pneumonia, acute coronary syndrome, and heart failure. The era of disease-specific and institution-specific—even physician-specific—reporting grows on a seemingly monthly basis.

Armed with this information, the PCP’s role shifts from managing the acute illnesses of their patients to understanding the report cards on their local hospitals and specialists and using this information to direct their patients to the hospitals and physicians who have the best outcomes. The expanding role of the PCP as the informed guide for their patients further will drive hospitals and all physicians who rely on referrals to improve their feedback and communication with PCPs.

We will begin to see that best-of-breed hospitals not only will have excellent clinical outcomes but will be pushed to have better patient-satisfaction and PCP-satisfaction scores. This is an opportunity for enlightened PCPs to use their medical background and hands-on understanding of local healthcare to be a vital resource to their patients.

By the same token, this is an opportunity for product differentiation for hospitals and their hospitalists to reshape a healthcare referral world traditionally built more on geography and familiarity than on information and performance, and replace it with strong communication and better outcomes. The best thing about this approach is the patient wins. TH

Dr. Wellikson is the CEO of SHM

Reference

1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-841.

Hospitalists have been concerned about the entire continuum of care from the early days of the hospital medicine movement. We have tried to look at the system of healthcare from the patients’ viewpoint, where an admission to the hospital is rare in the larger scheme of their healthcare and their interaction with a variety of physicians and health professionals.

Hospitalists will always need to rely on our professional relationships with surgeons and specialists, as well as with the primary care physicians (PCPs) who refer their patients for admission to the hospital and who partner with us to resume patient care at discharge.

With this fundamental backdrop, two interesting trends in the PCP world—the patient-centered medical home (PCMH) and PCPs’ use of performance measurements to drive referrals to hospitals and specialists—will have a profound effect on hospitalists, the patients we treat, and the systems of care in which we work.

PCMH and Hospitalists

For many years, the problems in primary care have been virtually ignored and dismissed by the insurance industry—and even by most of organized medicine. As if a light has suddenly been turned on, everyone now wants to “do something” to save primary care.

One of the latest “solutions’ is the PCMH. As we all know, ideas without funding are just ideas. It’s time to take note of PCMH. Why? Because insurance companies and Medicare are paying for a variety of pilot and demonstration projects to see how PCMH might play out in real-life interactions among patients and physicians.

The main new characteristics in the PCMH (as opposed to the traditional PCP) are a more robust information system and the commitment of personnel and organization within the PCP practice to allow proactive coordination of the patient’s care. The hope on the performance side is that patients will receive better care that will lead to better patient satisfaction and better outcomes. On the payment side, the PCP must receive significant monetary support to pay for the staff and equipment to coordinate and manage their patient’s journey through an increasingly complex series of tests, referrals, and treatments.

Accountability

SHM has tried to raise the issues of how the PCMH would relate to hospitalists at key junctures in the hospitalization continuum. Hopefully this will lead to a dialogue with the PCP community about how PCMH proposals would meet the goals of defining accountability and responsibility for the PCMH and for hospitalists. In turn this would lead to a better, safer system for our patients.

While discussions have specifically focused on the PCMH-hospitalist interface, many of the same tenets of accountability, responsibility, timeliness, and information transfer would apply to the PCMH-specialist interfaces.

Time of Admission

Accurate, timely information is crucial at the time of acute illness. It would be expected that at the time of the patient’s arrival at the hospital the following set of data elements would be available to the hospitalist (and/or emergency department physician or specialist). These elements are lifted directly from the joint SHM-ACP-SGIM Transitions of Care Consensus document from 2007 (available at www.hospitalmedicine.org): principle diagnosis and problem list; medication list (reconciliation), including over-the-counter and herbal products, allergies, and drug interactions; emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; test results/pending results; clearly identifies medical home and/or transferring coordinating physician/institution; patient’s cognitive status; advance directives, power of attorney, consent; planned interventions, durable medical equipment, wound care; and assessment of caregiver status.

Time of Discharge

While it is clear that the hospitalist is responsible for overseeing the patient’s care while hospitalized, it is essential for patients and their families to know who will be accountable at the time of discharge. SHM proposes that the PCMH:

• Assume the primary role of caring for the patient as of the time of discharge from the hospital;
• Provide a timely first post-discharge office visit consistent with the acute illness as documented in the discharge summary; and
• Ensure a handoff formally confirmed and documented by the hospitalist and PCMH.

The hospitalist should provide to the PCMH:

• An accurate and timely discharge summary; and
• The availability to the PCMH to answer questions about the hospitalization.

Further, discharge summaries should include:

• Primary and secondary diagnoses;
• Pertinent history and physical findings;
• Dates of hospitalization, treatment provided, brief hospital course;
• Results of procedures and abnormal laboratory tests;
• Recommendations of any subspecialty consultants;
• Information given to the patient and family;
• The patient’s condition or functional status at discharge;
• Reconciled discharge medication regimen, with reasons for any changes and indications for newly prescribed medications;
• Details of follow-up arrangements made;
• Specific follow-up needs, including appointments or procedures to be scheduled, and tests pending at the time of discharge; and
• Name and contact information of the responsible hospital physician.1

Other Considerations

Obviously other aspects of the PCMH-hospitalist relationship must be considered, including when the PCMH would like to be informed (or involved) during their patient’s hospitalization, as well as how to manage the handoff of responsibilities and information when the patient leaves the hospital but does not go directly home (e.g., when they are sent to a skilled nursing facility or rehabilitation center). If we continue to look at solutions from the patient’s and family’s points of view, we can come up with a workable solution.

Performance-driven Referral

Part of the result of the growth of the hospital medicine movement is that, increasingly, PCPs are not directly managing their patients for acute illnesses. That said, the PCP still has a significant role in determining whether their patients get the best care available—even if other physicians (e.g., hospitalists, surgeons, subspecialists) deliver the actual care.

We are just at the beginning of performance measurement and reporting. Today, PCPs and their patients can log on to www.hospitalcompare.hhs.gov and look at any hospital’s performance for pneumonia, acute coronary syndrome, and heart failure. The era of disease-specific and institution-specific—even physician-specific—reporting grows on a seemingly monthly basis.

Armed with this information, the PCP’s role shifts from managing the acute illnesses of their patients to understanding the report cards on their local hospitals and specialists and using this information to direct their patients to the hospitals and physicians who have the best outcomes. The expanding role of the PCP as the informed guide for their patients further will drive hospitals and all physicians who rely on referrals to improve their feedback and communication with PCPs.

We will begin to see that best-of-breed hospitals not only will have excellent clinical outcomes but will be pushed to have better patient-satisfaction and PCP-satisfaction scores. This is an opportunity for enlightened PCPs to use their medical background and hands-on understanding of local healthcare to be a vital resource to their patients.

By the same token, this is an opportunity for product differentiation for hospitals and their hospitalists to reshape a healthcare referral world traditionally built more on geography and familiarity than on information and performance, and replace it with strong communication and better outcomes. The best thing about this approach is the patient wins. TH

Dr. Wellikson is the CEO of SHM

Reference

1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-841.

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

Ed note: This article is the first in a series of interviews with members of Team Hospitalist: 12 hospital medicine experts who are serving a two-year term as special editorial consultants to our magazine.

Raajev Alexander, MD, is one busy hospitalist. For the past three years, he has been the lead hospitalist for the Oregon Medical Group, a group that caters to McKenzie-Willamette Medical Center in Springfield, Ore., and Sacred Heart Medical Center in Eugene, Ore. In addition to seeing about 15 patients a day, Dr. Alexander’s expertise in systems development has made him an attractive local expert. He serves on about five hospital committees (“I’ve lost track.”) and often attends meetings on his days off.

Dr. Alexander graduated from the University of Utah School of Medicine in 1995. After completing an internship and residency at Legacy Portland Hospital’s Internal Medicine program in 1998, he was recruited into the Oregon Medical Group.

He recently spoke with The Hospitalist about what he likes about his job, but why he also feels hospitalists should be compensated for the extra duties they undertake.

What attracted you to hospital medicine?

There is this kind of patient acuity where the sort of problems you’re solving seem important. Patients can have serious illnesses so you’re using your skills as an internist. I also like that there is a discreet arch to the hospitalization: There is the beginning of the hospitalization, the middle, the end, and then you’re sort of done. And I like that there is an interdisciplinary aspect; you work with nurses, care management, speech therapists, physical therapists, and ancillary therapists.

What are the challenges of leading a hospitalist group?

I do more than the full number of shifts per year. In addition to that, I go to meetings and deal with everything from a nurse calls and complaints about a hospitalist, to administration of the group. The CEO [of Oregon Medical Group] and I talk about staffing plans and how we can better serve the two hospitals in our area. I also sit on several hospital committees where I contribute my opinions on how to deploy pharmacists to how to redesign the case management program. My group finally decided to compensate me for certain meetings, but I still don’t get paid for half the meetings I go to.

Is this an issue other groups have?

I’m almost positive this is an ongoing issue for all hospitalist groups—at least I think it ought to be.

Hospitalists provide quality improvement on two different levels. One level is that, because we are in the hospital every day, we get to know the nurses, case managers, unit managers, lead respiratory therapists, and physical therapists. So, we effect change just by standing in the hallway.

The cross-education of pharmacists, nurses, and doctors is getting better every day. This is different from the way it used to be when a doctor had to run to the hospital at noon to see two patients, then run back to the office. Another way we improve quality is through committees. For all of the committees I sit on, the hospital gets get all my knowledge and ideas about systems, medications, and cross-reactions of drugs for free. But there isn’t enough time in my day to see patients, do nurse education and respiratory therapy education, to create protocols, and to sit on committees.

What’s the solution?

There are certain business models in hospital medicine that don’t make it possible to last as a hospitalist for 25 to 30 years. For example, there are some models where you get a bonus if you hit 18 to 20 patient encounters a day—even though those numbers are outside the SHM guidelines. If you’re seeing that many patients, you’re not providing optimal patient care.

A good business model is one where you can have 12 encounters per day and make a good living. Or see eight encounters per day and do administrative work, and still make a good living. The way to get there is for the specialty to better identify its mission and who its constituents are. TH

Ed note: This article is the first in a series of interviews with members of Team Hospitalist: 12 hospital medicine experts who are serving a two-year term as special editorial consultants to our magazine.

Raajev Alexander, MD, is one busy hospitalist. For the past three years, he has been the lead hospitalist for the Oregon Medical Group, a group that caters to McKenzie-Willamette Medical Center in Springfield, Ore., and Sacred Heart Medical Center in Eugene, Ore. In addition to seeing about 15 patients a day, Dr. Alexander’s expertise in systems development has made him an attractive local expert. He serves on about five hospital committees (“I’ve lost track.”) and often attends meetings on his days off.

Dr. Alexander graduated from the University of Utah School of Medicine in 1995. After completing an internship and residency at Legacy Portland Hospital’s Internal Medicine program in 1998, he was recruited into the Oregon Medical Group.

He recently spoke with The Hospitalist about what he likes about his job, but why he also feels hospitalists should be compensated for the extra duties they undertake.

What attracted you to hospital medicine?

There is this kind of patient acuity where the sort of problems you’re solving seem important. Patients can have serious illnesses so you’re using your skills as an internist. I also like that there is a discreet arch to the hospitalization: There is the beginning of the hospitalization, the middle, the end, and then you’re sort of done. And I like that there is an interdisciplinary aspect; you work with nurses, care management, speech therapists, physical therapists, and ancillary therapists.

What are the challenges of leading a hospitalist group?

I do more than the full number of shifts per year. In addition to that, I go to meetings and deal with everything from a nurse calls and complaints about a hospitalist, to administration of the group. The CEO [of Oregon Medical Group] and I talk about staffing plans and how we can better serve the two hospitals in our area. I also sit on several hospital committees where I contribute my opinions on how to deploy pharmacists to how to redesign the case management program. My group finally decided to compensate me for certain meetings, but I still don’t get paid for half the meetings I go to.

Is this an issue other groups have?

I’m almost positive this is an ongoing issue for all hospitalist groups—at least I think it ought to be.

Hospitalists provide quality improvement on two different levels. One level is that, because we are in the hospital every day, we get to know the nurses, case managers, unit managers, lead respiratory therapists, and physical therapists. So, we effect change just by standing in the hallway.

The cross-education of pharmacists, nurses, and doctors is getting better every day. This is different from the way it used to be when a doctor had to run to the hospital at noon to see two patients, then run back to the office. Another way we improve quality is through committees. For all of the committees I sit on, the hospital gets get all my knowledge and ideas about systems, medications, and cross-reactions of drugs for free. But there isn’t enough time in my day to see patients, do nurse education and respiratory therapy education, to create protocols, and to sit on committees.

What’s the solution?

There are certain business models in hospital medicine that don’t make it possible to last as a hospitalist for 25 to 30 years. For example, there are some models where you get a bonus if you hit 18 to 20 patient encounters a day—even though those numbers are outside the SHM guidelines. If you’re seeing that many patients, you’re not providing optimal patient care.

A good business model is one where you can have 12 encounters per day and make a good living. Or see eight encounters per day and do administrative work, and still make a good living. The way to get there is for the specialty to better identify its mission and who its constituents are. TH

Ed note: This article is the first in a series of interviews with members of Team Hospitalist: 12 hospital medicine experts who are serving a two-year term as special editorial consultants to our magazine.

Raajev Alexander, MD, is one busy hospitalist. For the past three years, he has been the lead hospitalist for the Oregon Medical Group, a group that caters to McKenzie-Willamette Medical Center in Springfield, Ore., and Sacred Heart Medical Center in Eugene, Ore. In addition to seeing about 15 patients a day, Dr. Alexander’s expertise in systems development has made him an attractive local expert. He serves on about five hospital committees (“I’ve lost track.”) and often attends meetings on his days off.

Dr. Alexander graduated from the University of Utah School of Medicine in 1995. After completing an internship and residency at Legacy Portland Hospital’s Internal Medicine program in 1998, he was recruited into the Oregon Medical Group.

He recently spoke with The Hospitalist about what he likes about his job, but why he also feels hospitalists should be compensated for the extra duties they undertake.

What attracted you to hospital medicine?

There is this kind of patient acuity where the sort of problems you’re solving seem important. Patients can have serious illnesses so you’re using your skills as an internist. I also like that there is a discreet arch to the hospitalization: There is the beginning of the hospitalization, the middle, the end, and then you’re sort of done. And I like that there is an interdisciplinary aspect; you work with nurses, care management, speech therapists, physical therapists, and ancillary therapists.

What are the challenges of leading a hospitalist group?

I do more than the full number of shifts per year. In addition to that, I go to meetings and deal with everything from a nurse calls and complaints about a hospitalist, to administration of the group. The CEO [of Oregon Medical Group] and I talk about staffing plans and how we can better serve the two hospitals in our area. I also sit on several hospital committees where I contribute my opinions on how to deploy pharmacists to how to redesign the case management program. My group finally decided to compensate me for certain meetings, but I still don’t get paid for half the meetings I go to.

Is this an issue other groups have?

I’m almost positive this is an ongoing issue for all hospitalist groups—at least I think it ought to be.

Hospitalists provide quality improvement on two different levels. One level is that, because we are in the hospital every day, we get to know the nurses, case managers, unit managers, lead respiratory therapists, and physical therapists. So, we effect change just by standing in the hallway.

The cross-education of pharmacists, nurses, and doctors is getting better every day. This is different from the way it used to be when a doctor had to run to the hospital at noon to see two patients, then run back to the office. Another way we improve quality is through committees. For all of the committees I sit on, the hospital gets get all my knowledge and ideas about systems, medications, and cross-reactions of drugs for free. But there isn’t enough time in my day to see patients, do nurse education and respiratory therapy education, to create protocols, and to sit on committees.

What’s the solution?

There are certain business models in hospital medicine that don’t make it possible to last as a hospitalist for 25 to 30 years. For example, there are some models where you get a bonus if you hit 18 to 20 patient encounters a day—even though those numbers are outside the SHM guidelines. If you’re seeing that many patients, you’re not providing optimal patient care.

A good business model is one where you can have 12 encounters per day and make a good living. Or see eight encounters per day and do administrative work, and still make a good living. The way to get there is for the specialty to better identify its mission and who its constituents are. TH

In a move that pleased many researchers, the Office of Human Research Protections (OHRP) in mid-February reversed its decision to shut down a Johns Hopkins Quality Improvement study in Michigan.

On the heels of an SHM-led coalition’s efforts, a letter to the Hopkins researchers said the OHRP decided to move on and would immediately lift its ban on data collection by the Michigan hospitals participating in the study.

At first glance the new decision appeared to be a victory for researchers and others who worried the OHRP’s earlier ruling might have a chilling effect on quality improvement (QI) studies. A closer examination of the agency’s response shows that while officials at the OHRP heard and reacted to the loud outcry from the medical community, they haven’t significantly changed their approach to regulating QI research.

In fact, the OHRP’s director explains the apparent about-face wasn’t really a reversal. It simply was a determination that the time for regulation already had passed—that essentially the horse already left the barn.

“Because the five-part intervention (including the checklist) has now been adopted by the Michigan hospitals as a proven effective standard of practice, the intervention no longer represents a research intervention with the patients at the hospitals, and is therefore not research involving human subjects,” says OHRP Director Ivor Pritchard, PhD. “And because Johns Hopkins is not receiving private, identifiable data from the Michigan hospitals, but rather de-identified data about the frequency of infections in the ICUs, this research activity is not research involving human subjects.”

What this means is the OHRP again may decide to step in if it were to receive a complaint about an ongoing QI study, like the Johns Hopkins project.

“Assuming [Health and Human Services] had the authority to regulate the activity, and the regulations had not changed, we would continue to advise institutions that such a QI study would fall under the U.S. Department of Health and Human Services (HHS) protection of human subject regulations,” Dr. Pritchard says. “Whether we would take a compliance action in response to a complaint about such a research activity is a different matter, however, and would depend on the specific facts of the case.”

The most recent letter to Johns Hopkins and Dr. Pritchard’s responses show there really hasn’t been any resolution to the problem, says Mary Ann Baily, PhD, an associate for ethics and health policy at the Hastings Center in Garrison, N.Y.

In fact, the letter to Johns Hopkins suggests a study with the exact design might again run afoul of the OHRP, Dr. Baily says.

Still, Dr. Pritchard’s comments show there have been some changes in the way the OHRP views its role when it comes to QI studies and this may impact the way the agency responds next time, Dr. Baily says.

Although Dr. Pritchard didn’t rule out the possibility a future study might be shut down, the agency appears to have become sensitized to the concerns of the research community. “Our current efforts are directed toward finding better ways to communicate the relationship between quality improvement and research to both the healthcare and research communities,” he explains. “At the same time we are also reviewing the application of these rules to QI activities like the Johns Hopkins project and whether any changes are needed to encourage such work.”

This is a good sign, Dr. Baily says. It shows an openness to outside opinions that hasn’t been obvious in the past, she adds.

QI researchers and healthcare experts also have been heartened by that newfound openness at the OHRP. It’s a solid signal that voices of protest were successful in grabbing the attention of OHRP officials, they say.

“The fact that they rescinded a prior ruling based on pushback from the field is quite important,” says Robert Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco, a former SHM president, and author of the blog “Wachter’s World” (www.wachtersworld.com). “It says that they have at least heard and responded to pressure from people doing this work.”

Unless there is a clear-cut set of rules that allow researchers to easily figure out when a study might catch the attention of the OHRP, many simply may decide against pursuing QI studies.

Dr. Wachter and others hope the latest communications from the OHRP are a sign officials at the agency are open to outside opinions and ready to start a dialogue.

That would be an important change, says Michael A. Matthay, MD, a professor of medicine and anesthesia at the University of California San Francisco. Up until now, the agency has been unfettered.

Dr. Matthay has had the experience of being second-guessed by the OHRP. In 2003, he was a researcher on a study sponsored and overseen by the National Institutes of Health. The research was brought to a screeching halt when officials at the OHRP decided they didn’t like the study’s design.

Although that study eventually was allowed to resume, the down time wasn’t without its costs, since it delayed results that eventually had a significant effect on patient care, says Dr. Matthay.

The Hopkins case is just another example of what happens when a government agency like the OHRP is allowed to act without oversight of its own actions, experts contend.

It highlights the agency’s ineffectiveness and inability to protect patient interests, Dr. Matthay suggests. “It’s not going to result in a better quality of care, and it’s not protecting patient rights,” he concludes.

“I’m a hopeful guy,” Dr. Wachter says. “If you’d asked me three months ago, when the ruling first came out, whether we would be able to get people an agency that had previously been impervious to public pressure to notice and pay attention, I might not have believed it.

“I think we’ve already gotten somewhere. This is just the first step. And it’s not a trivial first step. Federal agencies tend to turn off the phone and e-mail in response to pressure. We’ve shaken them by the shoulders. They have to realize how much turmoil they’re creating in the field and why this is going to be harmful to quality care of patients.” 

In one of the clearest signs that the “pushback” from researchers has had an effect, officials at the OHRP admitted the Hopkins case might have caused confusion among QI researchers. The agency would like to help clear things up, Dr. Pritchard says.

“Our impression is that many institutions are currently grappling with the challenges of determining when QI studies require [internal board review] and when informed consent should be required or waived,” he allows. “You should also be aware that, going forward, HHS officials will make a sincere effort to improve communications with medical providers and researchers so that quality improvement initiatives that pose minimal risks to subjects are not inhibited by the regulations. We’re also encouraging any providers or researchers with questions about these regulations to contact us for guidance. In addition, we’re reviewing the application of these rules to evidence-based quality improvement activities, like the Johns Hopkins project, and whether any changes are needed to encourage such work while safeguarding the rights and welfare of human subjects in research.”

Dr. Wachter and others hope there will be much more communication between researchers and the OHRP.

“My hope is that this is not done, that this is the beginning of a very important conversation,” Dr. Wachter says. “If it is done, then this has simply been a Pyrrhic victory.” TH

Linda Carroll is a medical writer based in New Jersey.

In a move that pleased many researchers, the Office of Human Research Protections (OHRP) in mid-February reversed its decision to shut down a Johns Hopkins Quality Improvement study in Michigan.

On the heels of an SHM-led coalition’s efforts, a letter to the Hopkins researchers said the OHRP decided to move on and would immediately lift its ban on data collection by the Michigan hospitals participating in the study.

At first glance the new decision appeared to be a victory for researchers and others who worried the OHRP’s earlier ruling might have a chilling effect on quality improvement (QI) studies. A closer examination of the agency’s response shows that while officials at the OHRP heard and reacted to the loud outcry from the medical community, they haven’t significantly changed their approach to regulating QI research.

In fact, the OHRP’s director explains the apparent about-face wasn’t really a reversal. It simply was a determination that the time for regulation already had passed—that essentially the horse already left the barn.

“Because the five-part intervention (including the checklist) has now been adopted by the Michigan hospitals as a proven effective standard of practice, the intervention no longer represents a research intervention with the patients at the hospitals, and is therefore not research involving human subjects,” says OHRP Director Ivor Pritchard, PhD. “And because Johns Hopkins is not receiving private, identifiable data from the Michigan hospitals, but rather de-identified data about the frequency of infections in the ICUs, this research activity is not research involving human subjects.”

What this means is the OHRP again may decide to step in if it were to receive a complaint about an ongoing QI study, like the Johns Hopkins project.

“Assuming [Health and Human Services] had the authority to regulate the activity, and the regulations had not changed, we would continue to advise institutions that such a QI study would fall under the U.S. Department of Health and Human Services (HHS) protection of human subject regulations,” Dr. Pritchard says. “Whether we would take a compliance action in response to a complaint about such a research activity is a different matter, however, and would depend on the specific facts of the case.”

The most recent letter to Johns Hopkins and Dr. Pritchard’s responses show there really hasn’t been any resolution to the problem, says Mary Ann Baily, PhD, an associate for ethics and health policy at the Hastings Center in Garrison, N.Y.

In fact, the letter to Johns Hopkins suggests a study with the exact design might again run afoul of the OHRP, Dr. Baily says.

Still, Dr. Pritchard’s comments show there have been some changes in the way the OHRP views its role when it comes to QI studies and this may impact the way the agency responds next time, Dr. Baily says.

Although Dr. Pritchard didn’t rule out the possibility a future study might be shut down, the agency appears to have become sensitized to the concerns of the research community. “Our current efforts are directed toward finding better ways to communicate the relationship between quality improvement and research to both the healthcare and research communities,” he explains. “At the same time we are also reviewing the application of these rules to QI activities like the Johns Hopkins project and whether any changes are needed to encourage such work.”

This is a good sign, Dr. Baily says. It shows an openness to outside opinions that hasn’t been obvious in the past, she adds.

QI researchers and healthcare experts also have been heartened by that newfound openness at the OHRP. It’s a solid signal that voices of protest were successful in grabbing the attention of OHRP officials, they say.

“The fact that they rescinded a prior ruling based on pushback from the field is quite important,” says Robert Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco, a former SHM president, and author of the blog “Wachter’s World” (www.wachtersworld.com). “It says that they have at least heard and responded to pressure from people doing this work.”

Unless there is a clear-cut set of rules that allow researchers to easily figure out when a study might catch the attention of the OHRP, many simply may decide against pursuing QI studies.

Dr. Wachter and others hope the latest communications from the OHRP are a sign officials at the agency are open to outside opinions and ready to start a dialogue.

That would be an important change, says Michael A. Matthay, MD, a professor of medicine and anesthesia at the University of California San Francisco. Up until now, the agency has been unfettered.

Dr. Matthay has had the experience of being second-guessed by the OHRP. In 2003, he was a researcher on a study sponsored and overseen by the National Institutes of Health. The research was brought to a screeching halt when officials at the OHRP decided they didn’t like the study’s design.

Although that study eventually was allowed to resume, the down time wasn’t without its costs, since it delayed results that eventually had a significant effect on patient care, says Dr. Matthay.

The Hopkins case is just another example of what happens when a government agency like the OHRP is allowed to act without oversight of its own actions, experts contend.

It highlights the agency’s ineffectiveness and inability to protect patient interests, Dr. Matthay suggests. “It’s not going to result in a better quality of care, and it’s not protecting patient rights,” he concludes.

“I’m a hopeful guy,” Dr. Wachter says. “If you’d asked me three months ago, when the ruling first came out, whether we would be able to get people an agency that had previously been impervious to public pressure to notice and pay attention, I might not have believed it.

“I think we’ve already gotten somewhere. This is just the first step. And it’s not a trivial first step. Federal agencies tend to turn off the phone and e-mail in response to pressure. We’ve shaken them by the shoulders. They have to realize how much turmoil they’re creating in the field and why this is going to be harmful to quality care of patients.” 

In one of the clearest signs that the “pushback” from researchers has had an effect, officials at the OHRP admitted the Hopkins case might have caused confusion among QI researchers. The agency would like to help clear things up, Dr. Pritchard says.

“Our impression is that many institutions are currently grappling with the challenges of determining when QI studies require [internal board review] and when informed consent should be required or waived,” he allows. “You should also be aware that, going forward, HHS officials will make a sincere effort to improve communications with medical providers and researchers so that quality improvement initiatives that pose minimal risks to subjects are not inhibited by the regulations. We’re also encouraging any providers or researchers with questions about these regulations to contact us for guidance. In addition, we’re reviewing the application of these rules to evidence-based quality improvement activities, like the Johns Hopkins project, and whether any changes are needed to encourage such work while safeguarding the rights and welfare of human subjects in research.”

Dr. Wachter and others hope there will be much more communication between researchers and the OHRP.

“My hope is that this is not done, that this is the beginning of a very important conversation,” Dr. Wachter says. “If it is done, then this has simply been a Pyrrhic victory.” TH

Linda Carroll is a medical writer based in New Jersey.

In a move that pleased many researchers, the Office of Human Research Protections (OHRP) in mid-February reversed its decision to shut down a Johns Hopkins Quality Improvement study in Michigan.

On the heels of an SHM-led coalition’s efforts, a letter to the Hopkins researchers said the OHRP decided to move on and would immediately lift its ban on data collection by the Michigan hospitals participating in the study.

At first glance the new decision appeared to be a victory for researchers and others who worried the OHRP’s earlier ruling might have a chilling effect on quality improvement (QI) studies. A closer examination of the agency’s response shows that while officials at the OHRP heard and reacted to the loud outcry from the medical community, they haven’t significantly changed their approach to regulating QI research.

In fact, the OHRP’s director explains the apparent about-face wasn’t really a reversal. It simply was a determination that the time for regulation already had passed—that essentially the horse already left the barn.

“Because the five-part intervention (including the checklist) has now been adopted by the Michigan hospitals as a proven effective standard of practice, the intervention no longer represents a research intervention with the patients at the hospitals, and is therefore not research involving human subjects,” says OHRP Director Ivor Pritchard, PhD. “And because Johns Hopkins is not receiving private, identifiable data from the Michigan hospitals, but rather de-identified data about the frequency of infections in the ICUs, this research activity is not research involving human subjects.”

What this means is the OHRP again may decide to step in if it were to receive a complaint about an ongoing QI study, like the Johns Hopkins project.

“Assuming [Health and Human Services] had the authority to regulate the activity, and the regulations had not changed, we would continue to advise institutions that such a QI study would fall under the U.S. Department of Health and Human Services (HHS) protection of human subject regulations,” Dr. Pritchard says. “Whether we would take a compliance action in response to a complaint about such a research activity is a different matter, however, and would depend on the specific facts of the case.”

The most recent letter to Johns Hopkins and Dr. Pritchard’s responses show there really hasn’t been any resolution to the problem, says Mary Ann Baily, PhD, an associate for ethics and health policy at the Hastings Center in Garrison, N.Y.

In fact, the letter to Johns Hopkins suggests a study with the exact design might again run afoul of the OHRP, Dr. Baily says.

Still, Dr. Pritchard’s comments show there have been some changes in the way the OHRP views its role when it comes to QI studies and this may impact the way the agency responds next time, Dr. Baily says.

Although Dr. Pritchard didn’t rule out the possibility a future study might be shut down, the agency appears to have become sensitized to the concerns of the research community. “Our current efforts are directed toward finding better ways to communicate the relationship between quality improvement and research to both the healthcare and research communities,” he explains. “At the same time we are also reviewing the application of these rules to QI activities like the Johns Hopkins project and whether any changes are needed to encourage such work.”

This is a good sign, Dr. Baily says. It shows an openness to outside opinions that hasn’t been obvious in the past, she adds.

QI researchers and healthcare experts also have been heartened by that newfound openness at the OHRP. It’s a solid signal that voices of protest were successful in grabbing the attention of OHRP officials, they say.

“The fact that they rescinded a prior ruling based on pushback from the field is quite important,” says Robert Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco, a former SHM president, and author of the blog “Wachter’s World” (www.wachtersworld.com). “It says that they have at least heard and responded to pressure from people doing this work.”

Unless there is a clear-cut set of rules that allow researchers to easily figure out when a study might catch the attention of the OHRP, many simply may decide against pursuing QI studies.

Dr. Wachter and others hope the latest communications from the OHRP are a sign officials at the agency are open to outside opinions and ready to start a dialogue.

That would be an important change, says Michael A. Matthay, MD, a professor of medicine and anesthesia at the University of California San Francisco. Up until now, the agency has been unfettered.

Dr. Matthay has had the experience of being second-guessed by the OHRP. In 2003, he was a researcher on a study sponsored and overseen by the National Institutes of Health. The research was brought to a screeching halt when officials at the OHRP decided they didn’t like the study’s design.

Although that study eventually was allowed to resume, the down time wasn’t without its costs, since it delayed results that eventually had a significant effect on patient care, says Dr. Matthay.

The Hopkins case is just another example of what happens when a government agency like the OHRP is allowed to act without oversight of its own actions, experts contend.

It highlights the agency’s ineffectiveness and inability to protect patient interests, Dr. Matthay suggests. “It’s not going to result in a better quality of care, and it’s not protecting patient rights,” he concludes.

“I’m a hopeful guy,” Dr. Wachter says. “If you’d asked me three months ago, when the ruling first came out, whether we would be able to get people an agency that had previously been impervious to public pressure to notice and pay attention, I might not have believed it.

“I think we’ve already gotten somewhere. This is just the first step. And it’s not a trivial first step. Federal agencies tend to turn off the phone and e-mail in response to pressure. We’ve shaken them by the shoulders. They have to realize how much turmoil they’re creating in the field and why this is going to be harmful to quality care of patients.” 

In one of the clearest signs that the “pushback” from researchers has had an effect, officials at the OHRP admitted the Hopkins case might have caused confusion among QI researchers. The agency would like to help clear things up, Dr. Pritchard says.

“Our impression is that many institutions are currently grappling with the challenges of determining when QI studies require [internal board review] and when informed consent should be required or waived,” he allows. “You should also be aware that, going forward, HHS officials will make a sincere effort to improve communications with medical providers and researchers so that quality improvement initiatives that pose minimal risks to subjects are not inhibited by the regulations. We’re also encouraging any providers or researchers with questions about these regulations to contact us for guidance. In addition, we’re reviewing the application of these rules to evidence-based quality improvement activities, like the Johns Hopkins project, and whether any changes are needed to encourage such work while safeguarding the rights and welfare of human subjects in research.”

Dr. Wachter and others hope there will be much more communication between researchers and the OHRP.

“My hope is that this is not done, that this is the beginning of a very important conversation,” Dr. Wachter says. “If it is done, then this has simply been a Pyrrhic victory.” TH

Linda Carroll is a medical writer based in New Jersey.

How does Martin Izakovic, MD, medical director of the hospitalist program at Mercy Hospital in Iowa City, Iowa, suggest keeping current with medical literature?

“Let your journals pile up in your office, including the free ones you never subscribed to, feel guilty about throwing any away, tell yourself you will get to them one day, and then watch as it almost never happens.”

Dr. Izakovic is kidding, of course, but it’s no joke trying to read the wealth of medical information published daily. In fact, some people call it impossible. So to stay afloat, many hospitalists go electronic or turn to journal clubs.

Electronic Resources to the Rescue

It’s not for lack of trying that you can’t get through all the literature out there. Most hospitalists we queried say they only skim through the major internal medicine-related journals, including the Annals of Internal Medicine, the Journal of the American Medical Association (JAMA), The New England Journal of Medicine, Lancet, the Journal of General Internal Medicine, and the Journal of Hospital Medicine.

What really keeps hospitalists apprised of the latest medical news and research, they say, comes to them by way of the World Wide Web—straight to their inboxes. To start, many register for e-mails of journal tables of contents. Others subscribe to the American College of Physicians Journal Club, which reviews and critiques journal articles, rates the relevance of each article on a five-point scale, offers a customized literature updating service, and bundles mailings with the Annals.

Some physicians, like Leora Horwitz, MD, assistant professor in the division of General Internal Medicine at Yale School of Medicine, New Haven, only wish to receive information pertinent to specific topics. To make this happen, Dr. Horwitz sets up a search through Ovid or PubMed that runs about every two weeks and flags new articles that match her criteria.

“I only do this for absolutely key areas and I make the search criteria very restrictive so I only get one to two hits a month at most,” she says. “Then I set up an alert for one or two major articles in each field I am interested in.”

Dr. Horwitz also sets up alerts for her own published articles.

Hospitalists who work at academic institutions, in particular, are inundated with information via grand rounds, lectures, and formats for topics related to hospital medicine.

Team Hospitalist Weighs In

“I am pretty rigorous about organization now, but it’s taken me several years to get it down,” says R. Neal Axon, MD, assistant professor in the departments of Internal Medicine and Pediatrics, Medical University of South Carolina, Charleston, and member of Team Hospitalist (hospitalist editorial advisors for this publication). “Few things are more frustrating than not being able to find the fact or article you want to reference in a convenient way.”

Dr. Axon subscribes to several journals at his home address (a favorite is the Annals of Internal Medicine, particularly the “Update in …” sections) and to two journals relevant to his research area, hypertension. “Over the years I’ve become much more selective in what I read,” he says. He marks articles of interest and culls through a stack in his office at least twice a month.

Dr. Axon also subscribes to The Hospitalist (“most useful by leaps and bounds, and the ‘In the Literature’ section is better than ever”) as well as Today’s Hospitalist and ACP Hospitalist (“the MKSAP review questions are useful”), which he browses and tends to read at night with the TV on in the background.

In the “Fund of Knowledge” folder on his computer he’s created subfolders organized by topic (“for example, Pulmonary, Renal, GI, Heme/Onc, Peri-op, Research, and Statistics”) and he keeps PDFs of useful articles for teaching, research, and publication. He uses EndNote to organize his bibliography.

Also, “my partners are pretty good about sharing articles of interest with the group by emailing pdf’s, and everyone has their own interest,” says Dr. Axon. “For instance, one of my partners has a particular interest in perioperative medicine, and his institution’s CMO, Patrick Cawley, MD, SHM’s current president, tends to circulate articles on quality improvement and hospital management.”—AS

“We’ll take a list of top conditions relevant to our practice, to review as a working group and then take that to the rest of the group to decide how we’ll standardize care,” says Julia S. Wright, MD, director of hospital medicine and an associate professor of medicine at the University of Wisconsin School of Medicine and Public Health, Madison.

On top of setting up specific searches, many hospitalists use their institutions’ subscriptions to services such as:

• UpToDate, the evidence-based, peer-reviewed electronic resource for doctors;
• InfoPOEMs, Patient-Oriented Evidence that Matters from Essential Evidence Plus;
• Epocrates and Micromedex, for drug-related information;
• JournalWATCH;
• The Medical Letter;
• The Hospitalist’s “In the Literature” department; and
• PubMed.

Physicians each have their favorite subscription services. Bill Stinnette, MD, a hospitalist for the Permanente Medical Group, Inc. at Kaiser Permanente San Rafael Medical Center in northern California, recommends MedPage Today daily headlines online as “an excellent source for breaking news and studies, with subspecialty areas, interactive features, FDA alerts, and CME.”

Kenneth Patrick, MD, hospitalist and ICU director of Chestnut Hill Hospital in Philadelphia, uses Medscape as his main online update method. After having completed a personalized profile of his interests, Dr. Patrick now receives e-mail links and general articles based on his criteria. “There’s no paper, it’s done at a convenient time and location, you don’t have to remember where you put that journal you were reading when you were interrupted, and there’s online CME credits,” he says.

Gatherings Become Informative Discussions

Despite enthusiasm about getting information electronically, many hospitalists continue to benefit from—and enjoy—good old-fashioned journal clubs. For example, the quarterly “Lunch and Learn” at the Hospital of St. Raphael in New Haven, Conn., developed by hospitalist Ilona Figura, MD, “has been a real hit,” says Steven Angelo, MD, director of hospitalist services there.

“On a rotating basis, each hospitalist presents an interesting case and leads our group in a discussion of the differential diagnosis, similar to what is done in the NEJM case presentations,” Dr. Angelo says. “At the end of the meeting, the presenter then provides the relevant points from the literature.”

Valerie J. Lang, MD, and her hospitalist colleagues in the division of Hospital Medicine at the University of Rochester (N.Y.) School of Medicine and Dentistry hold their own journal club twice a month. “We include the General Medicine division [their outpatient counterparts], which adds a nice perspective to our inpatient work,” she says.

Like the physicians at the Hospital of St. Raphael, these doctors also rotate topic selection and presentation. “For example, the last time [it was my turn], I presented a meta-analysis of DVT prophylaxis in medical inpatients along with a review of how to interpret meta-analyses,” Dr. Lang says.

The General Internal Medicine division at the University of Medicine and Dentistry of New Jersey in New Brunswick, where the four-person hospital medicine group (HMG) resides, takes a slightly different approach. The group has a weekly journal club, reviewing a month’s worth of four major journals, one per week, says Gabriela S. Ferreira, MD.

The Waterbury Hospital HMG, Waterbury, Conn., has its journal club once a month—at a restaurant. “One hospitalist presents an article, and then we eat and get drunk and have a generally good time,” says Rachel Lovins, MD, director of the hospitalist program.

When pressed about whether cocktail availability interferes with information retention, Dr. Lovins admits that’s the reason the presentations are made early in the evening. But she also backs down a bit: “We don’t actually get drunk but the social stuff is so important. It’s glue.”

Although the group totals 20 hospitalists, only a core group of six to 10 usually attends the dinners. Dr. Lovins makes sure everyone gets the pertinent information. “When I present an article, I always write up a summary page and hand it out at the meeting and also e-mail to the rest of the group,” she says. “But I’m a dork and no one else really does that.”

It’s All Timing

Sometimes it’s not about the method of receiving information, but about when and where you receive it. For example, when David Pressel, MD, PhD, director of Inpatient Service, General Pediatrics at Nemours Alfred I. duPont Hospital for Children in Wilmington, Del., encounters a patient with a new and different condition, he researches it immediately. “When learning is attached to a patient you see,” he says, “you’re more likely to cement that information in your mind.”

Dr. Wright uses a similar methodology. “I try to look up a couple of articles on every patient every day, with periodic reviews,” she says.

Other physicians, like Benny Gavi, MD, a hospitalist at Stanford Hospital & Clinics in California, print out articles of interest. “I take one or two articles in the pocket of my white coat to read when I have time, for example, when waiting for a meeting to start,” he says. “The pile is also near where I have lunch and I take an article when I eat.”

One hospitalist, who wishes to remain nameless, uses another time to get his literature scoop: at his daily poop, so to speak, during that block of time each day when he sits and reads. “Continuing education is a lifelong process and can happen anytime,” he says, whimsically. TH

Andrea Sattinger is a freelance writer based in North Carolina and a longtime contributor to The Hospitalist.

Reference

1. Bennett, HJ. A piece of my mind. Keeping up with the literature. JAMA. 1992;267(7):920.

How does Martin Izakovic, MD, medical director of the hospitalist program at Mercy Hospital in Iowa City, Iowa, suggest keeping current with medical literature?

“Let your journals pile up in your office, including the free ones you never subscribed to, feel guilty about throwing any away, tell yourself you will get to them one day, and then watch as it almost never happens.”

Dr. Izakovic is kidding, of course, but it’s no joke trying to read the wealth of medical information published daily. In fact, some people call it impossible. So to stay afloat, many hospitalists go electronic or turn to journal clubs.

Electronic Resources to the Rescue

It’s not for lack of trying that you can’t get through all the literature out there. Most hospitalists we queried say they only skim through the major internal medicine-related journals, including the Annals of Internal Medicine, the Journal of the American Medical Association (JAMA), The New England Journal of Medicine, Lancet, the Journal of General Internal Medicine, and the Journal of Hospital Medicine.

What really keeps hospitalists apprised of the latest medical news and research, they say, comes to them by way of the World Wide Web—straight to their inboxes. To start, many register for e-mails of journal tables of contents. Others subscribe to the American College of Physicians Journal Club, which reviews and critiques journal articles, rates the relevance of each article on a five-point scale, offers a customized literature updating service, and bundles mailings with the Annals.

Some physicians, like Leora Horwitz, MD, assistant professor in the division of General Internal Medicine at Yale School of Medicine, New Haven, only wish to receive information pertinent to specific topics. To make this happen, Dr. Horwitz sets up a search through Ovid or PubMed that runs about every two weeks and flags new articles that match her criteria.

“I only do this for absolutely key areas and I make the search criteria very restrictive so I only get one to two hits a month at most,” she says. “Then I set up an alert for one or two major articles in each field I am interested in.”

Dr. Horwitz also sets up alerts for her own published articles.

Hospitalists who work at academic institutions, in particular, are inundated with information via grand rounds, lectures, and formats for topics related to hospital medicine.

Team Hospitalist Weighs In

“I am pretty rigorous about organization now, but it’s taken me several years to get it down,” says R. Neal Axon, MD, assistant professor in the departments of Internal Medicine and Pediatrics, Medical University of South Carolina, Charleston, and member of Team Hospitalist (hospitalist editorial advisors for this publication). “Few things are more frustrating than not being able to find the fact or article you want to reference in a convenient way.”

Dr. Axon subscribes to several journals at his home address (a favorite is the Annals of Internal Medicine, particularly the “Update in …” sections) and to two journals relevant to his research area, hypertension. “Over the years I’ve become much more selective in what I read,” he says. He marks articles of interest and culls through a stack in his office at least twice a month.

Dr. Axon also subscribes to The Hospitalist (“most useful by leaps and bounds, and the ‘In the Literature’ section is better than ever”) as well as Today’s Hospitalist and ACP Hospitalist (“the MKSAP review questions are useful”), which he browses and tends to read at night with the TV on in the background.

In the “Fund of Knowledge” folder on his computer he’s created subfolders organized by topic (“for example, Pulmonary, Renal, GI, Heme/Onc, Peri-op, Research, and Statistics”) and he keeps PDFs of useful articles for teaching, research, and publication. He uses EndNote to organize his bibliography.

Also, “my partners are pretty good about sharing articles of interest with the group by emailing pdf’s, and everyone has their own interest,” says Dr. Axon. “For instance, one of my partners has a particular interest in perioperative medicine, and his institution’s CMO, Patrick Cawley, MD, SHM’s current president, tends to circulate articles on quality improvement and hospital management.”—AS

“We’ll take a list of top conditions relevant to our practice, to review as a working group and then take that to the rest of the group to decide how we’ll standardize care,” says Julia S. Wright, MD, director of hospital medicine and an associate professor of medicine at the University of Wisconsin School of Medicine and Public Health, Madison.

On top of setting up specific searches, many hospitalists use their institutions’ subscriptions to services such as:

• UpToDate, the evidence-based, peer-reviewed electronic resource for doctors;
• InfoPOEMs, Patient-Oriented Evidence that Matters from Essential Evidence Plus;
• Epocrates and Micromedex, for drug-related information;
• JournalWATCH;
• The Medical Letter;
• The Hospitalist’s “In the Literature” department; and
• PubMed.

Physicians each have their favorite subscription services. Bill Stinnette, MD, a hospitalist for the Permanente Medical Group, Inc. at Kaiser Permanente San Rafael Medical Center in northern California, recommends MedPage Today daily headlines online as “an excellent source for breaking news and studies, with subspecialty areas, interactive features, FDA alerts, and CME.”

Kenneth Patrick, MD, hospitalist and ICU director of Chestnut Hill Hospital in Philadelphia, uses Medscape as his main online update method. After having completed a personalized profile of his interests, Dr. Patrick now receives e-mail links and general articles based on his criteria. “There’s no paper, it’s done at a convenient time and location, you don’t have to remember where you put that journal you were reading when you were interrupted, and there’s online CME credits,” he says.

Gatherings Become Informative Discussions

Despite enthusiasm about getting information electronically, many hospitalists continue to benefit from—and enjoy—good old-fashioned journal clubs. For example, the quarterly “Lunch and Learn” at the Hospital of St. Raphael in New Haven, Conn., developed by hospitalist Ilona Figura, MD, “has been a real hit,” says Steven Angelo, MD, director of hospitalist services there.

“On a rotating basis, each hospitalist presents an interesting case and leads our group in a discussion of the differential diagnosis, similar to what is done in the NEJM case presentations,” Dr. Angelo says. “At the end of the meeting, the presenter then provides the relevant points from the literature.”

Valerie J. Lang, MD, and her hospitalist colleagues in the division of Hospital Medicine at the University of Rochester (N.Y.) School of Medicine and Dentistry hold their own journal club twice a month. “We include the General Medicine division [their outpatient counterparts], which adds a nice perspective to our inpatient work,” she says.

Like the physicians at the Hospital of St. Raphael, these doctors also rotate topic selection and presentation. “For example, the last time [it was my turn], I presented a meta-analysis of DVT prophylaxis in medical inpatients along with a review of how to interpret meta-analyses,” Dr. Lang says.

The General Internal Medicine division at the University of Medicine and Dentistry of New Jersey in New Brunswick, where the four-person hospital medicine group (HMG) resides, takes a slightly different approach. The group has a weekly journal club, reviewing a month’s worth of four major journals, one per week, says Gabriela S. Ferreira, MD.

The Waterbury Hospital HMG, Waterbury, Conn., has its journal club once a month—at a restaurant. “One hospitalist presents an article, and then we eat and get drunk and have a generally good time,” says Rachel Lovins, MD, director of the hospitalist program.

When pressed about whether cocktail availability interferes with information retention, Dr. Lovins admits that’s the reason the presentations are made early in the evening. But she also backs down a bit: “We don’t actually get drunk but the social stuff is so important. It’s glue.”

Although the group totals 20 hospitalists, only a core group of six to 10 usually attends the dinners. Dr. Lovins makes sure everyone gets the pertinent information. “When I present an article, I always write up a summary page and hand it out at the meeting and also e-mail to the rest of the group,” she says. “But I’m a dork and no one else really does that.”

It’s All Timing

Sometimes it’s not about the method of receiving information, but about when and where you receive it. For example, when David Pressel, MD, PhD, director of Inpatient Service, General Pediatrics at Nemours Alfred I. duPont Hospital for Children in Wilmington, Del., encounters a patient with a new and different condition, he researches it immediately. “When learning is attached to a patient you see,” he says, “you’re more likely to cement that information in your mind.”

Dr. Wright uses a similar methodology. “I try to look up a couple of articles on every patient every day, with periodic reviews,” she says.

Other physicians, like Benny Gavi, MD, a hospitalist at Stanford Hospital & Clinics in California, print out articles of interest. “I take one or two articles in the pocket of my white coat to read when I have time, for example, when waiting for a meeting to start,” he says. “The pile is also near where I have lunch and I take an article when I eat.”

One hospitalist, who wishes to remain nameless, uses another time to get his literature scoop: at his daily poop, so to speak, during that block of time each day when he sits and reads. “Continuing education is a lifelong process and can happen anytime,” he says, whimsically. TH

Andrea Sattinger is a freelance writer based in North Carolina and a longtime contributor to The Hospitalist.

Reference

1. Bennett, HJ. A piece of my mind. Keeping up with the literature. JAMA. 1992;267(7):920.

How does Martin Izakovic, MD, medical director of the hospitalist program at Mercy Hospital in Iowa City, Iowa, suggest keeping current with medical literature?

“Let your journals pile up in your office, including the free ones you never subscribed to, feel guilty about throwing any away, tell yourself you will get to them one day, and then watch as it almost never happens.”

Dr. Izakovic is kidding, of course, but it’s no joke trying to read the wealth of medical information published daily. In fact, some people call it impossible. So to stay afloat, many hospitalists go electronic or turn to journal clubs.

Electronic Resources to the Rescue

It’s not for lack of trying that you can’t get through all the literature out there. Most hospitalists we queried say they only skim through the major internal medicine-related journals, including the Annals of Internal Medicine, the Journal of the American Medical Association (JAMA), The New England Journal of Medicine, Lancet, the Journal of General Internal Medicine, and the Journal of Hospital Medicine.

What really keeps hospitalists apprised of the latest medical news and research, they say, comes to them by way of the World Wide Web—straight to their inboxes. To start, many register for e-mails of journal tables of contents. Others subscribe to the American College of Physicians Journal Club, which reviews and critiques journal articles, rates the relevance of each article on a five-point scale, offers a customized literature updating service, and bundles mailings with the Annals.

Some physicians, like Leora Horwitz, MD, assistant professor in the division of General Internal Medicine at Yale School of Medicine, New Haven, only wish to receive information pertinent to specific topics. To make this happen, Dr. Horwitz sets up a search through Ovid or PubMed that runs about every two weeks and flags new articles that match her criteria.

“I only do this for absolutely key areas and I make the search criteria very restrictive so I only get one to two hits a month at most,” she says. “Then I set up an alert for one or two major articles in each field I am interested in.”

Dr. Horwitz also sets up alerts for her own published articles.

Hospitalists who work at academic institutions, in particular, are inundated with information via grand rounds, lectures, and formats for topics related to hospital medicine.

Team Hospitalist Weighs In

“I am pretty rigorous about organization now, but it’s taken me several years to get it down,” says R. Neal Axon, MD, assistant professor in the departments of Internal Medicine and Pediatrics, Medical University of South Carolina, Charleston, and member of Team Hospitalist (hospitalist editorial advisors for this publication). “Few things are more frustrating than not being able to find the fact or article you want to reference in a convenient way.”

Dr. Axon subscribes to several journals at his home address (a favorite is the Annals of Internal Medicine, particularly the “Update in …” sections) and to two journals relevant to his research area, hypertension. “Over the years I’ve become much more selective in what I read,” he says. He marks articles of interest and culls through a stack in his office at least twice a month.

Dr. Axon also subscribes to The Hospitalist (“most useful by leaps and bounds, and the ‘In the Literature’ section is better than ever”) as well as Today’s Hospitalist and ACP Hospitalist (“the MKSAP review questions are useful”), which he browses and tends to read at night with the TV on in the background.

In the “Fund of Knowledge” folder on his computer he’s created subfolders organized by topic (“for example, Pulmonary, Renal, GI, Heme/Onc, Peri-op, Research, and Statistics”) and he keeps PDFs of useful articles for teaching, research, and publication. He uses EndNote to organize his bibliography.

Also, “my partners are pretty good about sharing articles of interest with the group by emailing pdf’s, and everyone has their own interest,” says Dr. Axon. “For instance, one of my partners has a particular interest in perioperative medicine, and his institution’s CMO, Patrick Cawley, MD, SHM’s current president, tends to circulate articles on quality improvement and hospital management.”—AS

“We’ll take a list of top conditions relevant to our practice, to review as a working group and then take that to the rest of the group to decide how we’ll standardize care,” says Julia S. Wright, MD, director of hospital medicine and an associate professor of medicine at the University of Wisconsin School of Medicine and Public Health, Madison.

On top of setting up specific searches, many hospitalists use their institutions’ subscriptions to services such as:

• UpToDate, the evidence-based, peer-reviewed electronic resource for doctors;
• InfoPOEMs, Patient-Oriented Evidence that Matters from Essential Evidence Plus;
• Epocrates and Micromedex, for drug-related information;
• JournalWATCH;
• The Medical Letter;
• The Hospitalist’s “In the Literature” department; and
• PubMed.

Physicians each have their favorite subscription services. Bill Stinnette, MD, a hospitalist for the Permanente Medical Group, Inc. at Kaiser Permanente San Rafael Medical Center in northern California, recommends MedPage Today daily headlines online as “an excellent source for breaking news and studies, with subspecialty areas, interactive features, FDA alerts, and CME.”

Kenneth Patrick, MD, hospitalist and ICU director of Chestnut Hill Hospital in Philadelphia, uses Medscape as his main online update method. After having completed a personalized profile of his interests, Dr. Patrick now receives e-mail links and general articles based on his criteria. “There’s no paper, it’s done at a convenient time and location, you don’t have to remember where you put that journal you were reading when you were interrupted, and there’s online CME credits,” he says.

Gatherings Become Informative Discussions

Despite enthusiasm about getting information electronically, many hospitalists continue to benefit from—and enjoy—good old-fashioned journal clubs. For example, the quarterly “Lunch and Learn” at the Hospital of St. Raphael in New Haven, Conn., developed by hospitalist Ilona Figura, MD, “has been a real hit,” says Steven Angelo, MD, director of hospitalist services there.

“On a rotating basis, each hospitalist presents an interesting case and leads our group in a discussion of the differential diagnosis, similar to what is done in the NEJM case presentations,” Dr. Angelo says. “At the end of the meeting, the presenter then provides the relevant points from the literature.”

Valerie J. Lang, MD, and her hospitalist colleagues in the division of Hospital Medicine at the University of Rochester (N.Y.) School of Medicine and Dentistry hold their own journal club twice a month. “We include the General Medicine division [their outpatient counterparts], which adds a nice perspective to our inpatient work,” she says.

Like the physicians at the Hospital of St. Raphael, these doctors also rotate topic selection and presentation. “For example, the last time [it was my turn], I presented a meta-analysis of DVT prophylaxis in medical inpatients along with a review of how to interpret meta-analyses,” Dr. Lang says.

The General Internal Medicine division at the University of Medicine and Dentistry of New Jersey in New Brunswick, where the four-person hospital medicine group (HMG) resides, takes a slightly different approach. The group has a weekly journal club, reviewing a month’s worth of four major journals, one per week, says Gabriela S. Ferreira, MD.

The Waterbury Hospital HMG, Waterbury, Conn., has its journal club once a month—at a restaurant. “One hospitalist presents an article, and then we eat and get drunk and have a generally good time,” says Rachel Lovins, MD, director of the hospitalist program.

When pressed about whether cocktail availability interferes with information retention, Dr. Lovins admits that’s the reason the presentations are made early in the evening. But she also backs down a bit: “We don’t actually get drunk but the social stuff is so important. It’s glue.”

Although the group totals 20 hospitalists, only a core group of six to 10 usually attends the dinners. Dr. Lovins makes sure everyone gets the pertinent information. “When I present an article, I always write up a summary page and hand it out at the meeting and also e-mail to the rest of the group,” she says. “But I’m a dork and no one else really does that.”

It’s All Timing

Sometimes it’s not about the method of receiving information, but about when and where you receive it. For example, when David Pressel, MD, PhD, director of Inpatient Service, General Pediatrics at Nemours Alfred I. duPont Hospital for Children in Wilmington, Del., encounters a patient with a new and different condition, he researches it immediately. “When learning is attached to a patient you see,” he says, “you’re more likely to cement that information in your mind.”

Dr. Wright uses a similar methodology. “I try to look up a couple of articles on every patient every day, with periodic reviews,” she says.

Other physicians, like Benny Gavi, MD, a hospitalist at Stanford Hospital & Clinics in California, print out articles of interest. “I take one or two articles in the pocket of my white coat to read when I have time, for example, when waiting for a meeting to start,” he says. “The pile is also near where I have lunch and I take an article when I eat.”

One hospitalist, who wishes to remain nameless, uses another time to get his literature scoop: at his daily poop, so to speak, during that block of time each day when he sits and reads. “Continuing education is a lifelong process and can happen anytime,” he says, whimsically. TH

Andrea Sattinger is a freelance writer based in North Carolina and a longtime contributor to The Hospitalist.

Reference

1. Bennett, HJ. A piece of my mind. Keeping up with the literature. JAMA. 1992;267(7):920.

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.