Hospital Medicine: The Hub of the Healthcare Continuum

HealthLeaders magazine , June 13, 2010

Fleming: Since this is the only business we're in, we think about training and development differently. Physicians coming out of medical school are highly trained scientists, but they haven't spent much time thinking about the importance of being responsive to the emergency room, meeting the hospital's needs, serving on committees, being responsive to the referring doctors in the community, and the importance of billing and coding. Every physician that joins Cogent gets three or four days of initial training. We then supplement that training with regular follow-up, because over time you modify behavior by reinforcing, measuring, and setting standards.

HealthLeaders: Let's talk about information transfer. How do you make sure that you get the critical information about that patient from one physician to another?

McDowell: One of my frustrations is looking at how we've used technology to add work, as opposed to make work better, and it fascinates me to see people who are writing things down so they can enter it into the computer. We have to leverage technology to make our work easier as opposed to harder.

Hamby: We run the risk of electronification of a crappy process. I'm hoping our lesson learned is to try to use the technology more like it comes out of the box than see it as a blank slate that you can customize.

Fleming: We have to adapt our system to the hospital. Our order sets have to go through their forms committee, so in every hospital it's a tailored process. Every hospital is different, so what we practice is integrating and adapting.

HealthLeaders: Let's talk about integration between hospitalists and intensivists.

Fleming: Our next big initiative is to move into ICUs by offering intensivist services. In most communities, there are not nearly enough ICU physicians, so we think good synergy can be developed between the hospitalist program and an intensivist program. If you only have one intensivist in the community, you could have that individual supplemented by the hospitalist program, with proper integration. Right now, we have a national board of intensive care doctors who are developing best practice standards that we plan to roll out across the country.

Hamby: Back in 2000, we got excited about building an intensivist program within a large community hospital. But we didn't have enough physicians who wanted to do that exclusively. What we've seen is a gradual migration to where our intensivists are employed and that's all they do full-time. They're under the same governance structure, same employment model as the hospitalist. So all the back office stuff is integrated.

HealthLeaders: What is the hospitalist's role in coordinating care under a global payment regime, and can hospitalists help reduce risk under that payment system?

Hamby: One of the challenges with the accountable care organization model is getting the claims data from CMS. I know there's a lot of work ongoing to make that happen, but I haven't heard yet of a case where that's actually happened. So you know, as the government sets up all these safe harbors for doing this experimentation with different models of financing care, we've got to make sure the government provides the claims data necessary to make it work.

Fleming: The area of risk we haven't talked about is that hospitalists have lower claims than for the general medical population, and it's reflected in our malpractice premiums. I think it's because hospital medicine programs generally spend more time using order sets and standardized approaches.

Ranney: Rules-based approaches based on evidence work very well to do that; it's been proven over and over again. That's an advantage to hospitalists.

HealthLeaders: How do we change the perception of the hospitalist's role as being seen as transitory or anonymous?

Fleming: The good news is that hospital medicine is the fastest-growing specialty in the history of medicine. We now are moving in the direction of board certification, so the physician can first get trained and boarded in internal medicine, and sometimes in family medicine or other specialties, and they get additionally certified in hospital medicine. The conversations earlier about being treated as house doctors and those kinds of things still exist in programs, but we're evolving away from that and hospital medicine is being seen as a true specialty.

McDowell: We've tried to build a sense of camaraderie among the group, so as opposed to somebody who is just coming in and doing a shift, they're a part of a team. Also, we pay for our hospitalists to belong to the Society of Hospital Medicine. I think there are analogies with emergency medicine. My dad was the first community hospital ER doc in Connecticut in 1967. Over the next few years, he hired retired surgeons and anesthesiologists who were in their mid-fifties, who would work for 10 years in the ER. Now what we have is that almost everyone who does emergency medicine has done an ER residency and is boarded in ER medicine.

Hamby: One of our particularly innovative hospitalists, who is now CMO at our big hospital, has developed dedicated hospitalist units. The hospitalist that is assigned to be in that unit that day is there all day. The collaboration, going over the list of patients with one person, has been a huge satisfier not only for the nurses, but also the hospitalists. We've seen significant length-of-stay improvements, cost per case, quality measures. It's hard to scale that in a smaller hospital, but we've had good success with that and I would recommend it.

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