Medicolegal Issues

Key Keynotes


 

The 10-year anniversary of SHM was an occasion not for looking back on the first decade of the organization, but for looking ahead.

In addition to seven tracks of educational sessions and ample opportunities for networking, SHM’s 10th Annual Meeting, held May 23-25 in Dallas, provided opportunities to get a big-picture glimpse into the future of hospital medicine, in the form of some eye-opening plenary sessions.

Coming Soon: Hospital Medicine Certification

Annual Meeting attendees heard from Robert M. Wachter, MD, and past-SHM President Mary Jo Gorman, MD, MBA, on “Certification in Hospital Medicine: What Does This Mean to Hospitalists? To Employers? To Patients?” The two outlined how the American Board of Internal Medicine (ABIM) is developing a Focused Recognition for Hospital Medicine through its Maintenance of Certification (MOC) system.

Dr. Wachter, who chairs the ABIM Committee on Hospital Medicine Focused Recognition, explained that the focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time ABIM has offered focused recognition for any subset of internal medicine—and, if approved, the first time the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

“This is a brand new idea,” stressed Dr. Wachter. “One of the exciting things—the challenging things—is that this is a first step toward the broader issue of how to certify based on experience rather than just training.”

Pre-Courses Provide In-Depth Learning

The Annual Meeting included six all-day or half-day pre-courses offered May 23. Geri L. Barnes, SHM’s director of Education and Quality Initiatives, says that typically 60% to 70% of annual meeting attendees sign up for a pre-course, and attendance in Dallas was in line with that average.

Some pre-courses have been offered previously. For example, “Best Practices in Managing a Hospital Medicine Program” is offered every year because the topic has been deemed popular enough or vital enough to warrant offering again.

“The Annual Meeting Committee basically recommends the topics for pre-courses,” says Barnes. But their decisions are based on the Core Competencies in Hospital Medicine. “[This document] drives the content of our breakout sessions and the pre-courses. We try to meld the pre-courses with the tracks offered at the Annual Meeting. For instance, we talked about offering a palliative care pre-course here in Dallas, but we ended up including a session track on the topic instead. We try to offer a complete package.”

The pre-courses offered in Dallas included:

  • “Best Practices in Managing a Hospital Medicine Program” by Joseph A. Miller, MS
  • “Critical Care Medicine for the Hospitalist” by Sheri Chernetsky Tejedor, MD
  • “High Impact Quality Improvement: How to Ensure a Successful Project” by Gregory Maynard, MD, and Tosha B. Wetterneck, MD
  • “Fundamentals of Inpatient Coding and Documentation: Getting Paid What You Deserve” by Leslie A. Flores, MHA
  • “Perioperative Medicine for the Hospitalist’’ by Shaun Frost, MD
  • “PICC Line Placement for Pediatric and Adult Hospitalists” by Nancy Moureau, BSN, CRNI — JJ

A Look at Digital Medicine

Informally known as the “health technology czar,” David J. Brailer, MD, PhD, served as the first national coordinator for Health Information Technology, at the Department of Health and Human Services until he resigned in April 2006. He is vice chairman of the American Health Information Community, and based on his plenary session “Health Care’s Digital Era: Implications for Hospitalists,” he is obviously familiar with hospital medicine.

“Hospitalists and health IT are co-factors in the same equation of change in healthcare,” said Dr. Brailer. “I can’t see how one can exist without the other.”

He went on to explain that hospitals must lead the way for digital medicine, as they are the institutions with the most opportunity for cost reductions in healthcare, the most opportunity for error reduction (“I’m not saying hospitals have the most errors, but that the corporatized process allows them to reduce errors that occur there,” he clarified), and the best site for innovation to move to a virtual model such as e-ICUs and new tele-specialties.

“And who can we turn to who ‘gets it,’ who can make all this happen?” asked Dr. Brailer of the innovations. “It won’t be the cardiologists, or the emergency department doctors. The obvious answer is that it will be the hospitalists.”

He warned that in order for hospitalists to be change agents, they must first take on the role of leaders of other doctors in inpatient care. “Some [hospitalists] don’t want to take on this role; others are already doing it,” he said. “I think that doctors need this leadership and I can’t think of a better group to do it than hospitalists. They’re going to have to step up to the plate on this.”

Dr. Brailer listed big issues coming up for hospitals, predicting that they will become “the hub of chronic-care management, leaders in adopting state-of-the-art technology, and leaders in quality improvement. Hospitalists are attached to each of these.” He explained that in chronic-care management, patients with chronic illnesses are cared for in a continuum-based way. Currently, inpatient care is the anchor not just for treatment, but for monitoring weight or assessing daily function levels. With chronic-care management, doctors can monitor patients without having them come into the office or the hospital.

“Primary-care doctors won’t be able to perform this off-site monitoring; they don’t have the time or the infrastructure,” explained Dr. Brailer. “But this is exactly what hospitals already do. Electronic monitoring is a real opportunity for them—and for hospitalists—to expand their care offerings.”

In spite of this expansion, he warned that hospitals will be in danger if they don’t change with the times. “The world is moving away from hospital-based care and toward [patient]-centered care,” he stated. “This is apparent in the current push for portability of patient-care information, and in today’s healthcare transparency issues. These are not hospital-friendly measures; in fact, they threaten hospitals to some degree. I hope that these trends will challenge hospitals to question how changes apply to them.”

Dr. Brailer ended with an update on public policy regarding healthcare—not a pretty picture from his insider’s view.

“Not much will happen in the next two years,” he predicted. “The FDA will pass the Prescription Drug User Fee program, and SCHIP [State Children’s Health Insurance Program] will pass in Washington D.C. I don’t think anything else will make it through the thicket of everything else going on.”

He also warned that regardless of who the next president of the U.S. is, nothing much will happen with healthcare reform. “It’s a high-priority item, but not high enough to warrant significant attention,” he said. “In the long term, it will get major attention, but probably only as a result of a catastrophe.”

Factors That Will Shape Our Future

On Friday morning, attendees heard from Jonathan B. Perlin, MD, PhD, MSHA, former under secretary for health at the Veterans Affairs, and currently the chief medical officer and senior vice-president of quality for Hospital Corporation of America (HCA) in Nashville, Tenn.—the nation’s largest hospital group.

In presenting, “Healthcare 2015: Challenges and Opportunities in the Decade Ahead,” Dr. Perlin threaded together the factors that will drive healthcare to a new level in the next eight years: the health needs of the population, including aging and the complications of diabetes, the increased requirements for delivering value, the economic pressures, and the technological changes and decentralization of healthcare delivery. Dr. Perlin, a leader in healthcare transformation and health information technology who has been termed a “clinical futurist,” pointed out that the result of these factors will be a transformation from an industrial to an information age model of healthcare.

Dr. Perlin traced the path being shaped by these challenges and opportunities, explaining that the economics of healthcare are creating pressure on the environment and disrupting the status quo. “Costs are increasing rapidly,” he stated. “It’s pretty clear that we’ve already hit some statutory alarms in the Medicare trust fund. Estimates now indicate that the trust fund will be bankrupt by 2018; we can either limit what we do or we can find better value in delivery of care.”

Response to economic pressure by Medicare and private insurers, said Dr. Perlin, provides a construct for change.

“The private sector, the government, and employers are all saying that we’re not going to buy units of healthcare services any more, we’re going to buy outcomes,” stressed Dr. Perlin. “The result is that performance becomes a gate function for even doing business in the new world.”

Toying with modest incentives in current pay-for-performance models will soon be trumped. “Medicare is changing from an incentive for simply reporting [with the current “Reporting Hospital Quality Data for Annual Payment Update” program] to value-based purchasing,” Dr. Perlin pointed out. Similarly, private insurers are differentiating performance levels and using lower co-pays to direct patients to better performers and high co-pays to redirect patients away from lower performers.

To participate in this new world of value-based purchasing and what Dr. Perlin termed “tiering and steering,” the healthcare industry must reorganize ways that it has traditionally provided care. Pen and paper are replaced by electronic health records. A locus of care is replaced by an interoperable, coordinated cooperative information network.

“The patient is the point of care in the new system, whether supported by glucometers that feed data into a central system,” said Dr. Perlin, “or a heart failure patient is tracked after discharge with a digital scale … or whether it is a hospitalist who reaches into the traditional healthcare setting with remote monitoring to provide round-the-clock support to a critically ill patient.”

In addition to providing enhanced safety, quality, continuity, and efficiency, new systems like these will provide central information sources, powerful in providing real-time, clinical decision-support, as well as generating new knowledge about disease, treatment and service delivery. The tremendous data available will reveal previously unnoticed patterns and provide more support for evidence-based care.

“Medicare and private insurers are focusing more on evidence-based care and are increasingly ambivalent about decisions not supported by evidence,” observed Dr. Perlin.

His view of the near future of healthcare was followed later that day with another plenary session that mulled how hospital medicine might look a decade from now.

Now It’s Time to Say Goodbye …

Dr. Wachter traditionally closes each Annual Meeting with a review of how far the young field of hospital medicine has come.

But at the 10th Annual Meeting, Dr. Wachter chose not to look back but to peer into his crystal ball. His presentation, “The Hospitalist Movement Two Decades Later: A Letter from the Future,” took the form of a letter from his future self, written in 2017, to SHM CEO Larry Wellikson, MD, as each man settles into a long-term care facility.

Dr. Wachter outlined the major forces starting to affect hospital medicine and imagined where they would lead us. And he couldn’t resist one glimpse back in time: “Think about the change we’ve seen already,” he marveled. “There’s no field in modern medical history that’s grown this quickly. We’re both leading the way and riding the waves.”

Dr. Wachter admitted his initial estimates for phenomenal growth of the field are already surpassed. “We originally projected that there would be 20,000 or 30,000 hospitalists,” he said. “Well, we’re already over 20,000. Now I’m thinking the final number will be around 50,000 or 60,000.”

He attributed part of that growth to several changes, including the additional responsibility of hospitalists for caring for surgical patients—something he sees as eventually becoming the norm. Another factor is the role hospitalists play in replacing residents in teaching hospitals, an area that has seen unplanned growth.

And finally, Dr. Wachter speculated that the quality measures movement will also boost the ranks of hospitalists. “We’re already seeing tremendous pressure on hospitalists to help their hospitals achieve success in pay-for-performance programs and in publicly reported measures,” he said. “This type of responsibility was originally considered a nice add-on for using hospitalists, but now it’s getting to be a crucial part. There’s a building expectation that hospitalists will guarantee superb performance.”

Dr. Wachter also touched on how information technology might change hospital medicine. “IT will definitely have an impact, in some exciting ways, and in other ways that have not been thought through,” he warned. “For example, consultation may be very different.” For example, a hospitalist in 2017 may be able to use a video link at a patient’s bedside to consult with one of 100 cardiologists around the country or around the world.

Following Dr. Wachter’s view of the future, Sylvia C. McKean, MD, had the last word at the meeting. As the chair in charge of next year’s Annual Meeting in San Diego, she presented the wrap-up on Friday afternoon, covering “What Have We Learned.”

Looking back on the previous three days, Dr. Mc­Kean pronounced, “The future is now.” Pointing to the number of meeting sessions, abstracts and poster presentations that emphasized recent innovations in hospital medicine, she said, “The Annual Meeting helps us find our expertise as hospitalists.” The Annual Meeting, along with SHM’s published Core Competencies helps define the role that hospitalists play in patient-centered care and in patient safety.

Dr. McKean thanked Chad Whelan, chair of the Annual Meeting Committee, for all his work, and said she was looking forward to 2008.

Chapter Reports

Chicago

On Feb. 22, the Chicago chapter met at Nick’s Fishmarket. Hospitalists, residents, and discharge planners were in attendance. Tarek Karamen, MD, and Kevin O’Leary, MD, briefly outlined the agenda of the evening and shared event details of the chapter’s June meeting.

After a lecture called “The Treatment of the Agitated Patient,” members from various hospitalists groups in Chicago introduced their programs and gave specifics of each. Residents seeking new positions were encouraged to network with hospitalists groups in attendance. At the next meeting, attendees suggested having an emphasis placed on hospitalists and primary-care physicians. The meeting was sponsored by Pfizer.

Indiana

The inaugural meeting of the SHM Indiana Chapter was held March 13. Chapter President Sam Bagchi, MD, moderated a lively roundtable discussion regarding the practice of hospital medicine in Indiana. Several topics for future meetings were discussed, including recruitment/retention of hospitalists in the region, use of allied healthcare providers in hospital-based practices, establishment of medical student outreach program, burnout avoidance, and ideas to expand the reach of the Indiana SHM Chapter and implementation of patient-oriented evidence.

A survey of event attendees revealed that most favored having quarterly meetings with a concentration on educational and practice management topics as well as more one-on-one networking time. The chapter’s next meeting was set for June 5 at Ruth’s Chris Steakhouse and was to feature SHM board member Alpesh Amin, MD, speaking on in-hospital glycemic control and the future of hospital medicine.

Las Vegas

The Las Vegas chapter met Nov. 16, 2006. Gary Skankey, MD, gave a presentation on intra-abdominal infections, followed by a talk from chapter President Will Watanabe, MD, that outlined the chapter’s agenda for 2007. The chapter’s focus will be on educating fellow hospitalists and subspecialists about sepsis. Dr. Watanabe gave a presentation regarding care of the sepsis patient. The Las Vegas Chapter plans on sponsoring a two-day conference in September, “The Sepsis Continuum of Care: Integrating a Multidisciplinary Approach to Sepsis.” The November meeting was sponsored by Wyeth.

Montana

The Montana Chapter gathered in Bozeman at Boodles Restaurant on Feb. 28. The meeting included a review of hospitalist programs in the state, as well as a discussion of challenges facing Montana, such as staffing, sparse population, and quality of care. Also discussed: program diversity within the state, including size of the programs and their scope and management structure. The chapter will hold its next meeting in June or July in Bozeman. That session will highlight correct operational success and challenges with a guest speaker. The chapter will also hold chapter elections at its next meeting.

New Jersey

On March 21, the New Jersey Chapter of SHM held its March CME event in Bridgewater. The presentation topic of the night was “Cross Cultural Approach to Patient Centered Care.” Debbie Salas-Lopez, MD, member of the N.J. Board of Medical Examiners, and Valerie Allusson, MD, director of the Physician Assistance Program Morristown Memorial Hospital, each gave presentations and referenced various case studies as examples. All attendees received two CME credits for the lecture.

Pacific Northwest

The Pacific Northwest chapter held its quarterly meeting Feb. 15 at the Columbia Tower in Seattle. Thirty local hospitalists, residents, and other interested parties representing 13 hospital medicine groups attended this meeting. The program was presided over by Deborah L. Washington, MD of the Pacific Medical Centers. David Spach, MD, of the University of Washington Medical Center gave a talk on “Case Studies in the Management of Serious Infections (with an Emphasis on MRSA).” Dr. Spach presented a variety of infectious disease cases.

The next meeting is expected to feature past president Joseph Bennet, MD, speaking on Hospitalist Practice in New Zealand and Tamara Roe, MD, speaking on the legal aspects of Hospital Medicine including contracts, non-competes, malpractice, and employment. This meeting was sponsored by Ortho-McNeil, Kindred Hospital, Scios Inc., and Cubist Pharmaceuticals.

Philadelphia

On March 13, the Philadelphia Chapter gathered for its semi-annual meeting. The guest speaker for the night was Scott Manaker, MD, PhD, associate professor of Medicine and Pharmacology and vice chair for Regulatory Affairs, Department of Medicine, University of Pennsylvania. Dr. Manaker spoke about “Billing and Coding for the Hospitalist: What’s In An RVU For You?” The presentation prompted many audience questions. The program was sponsored by Pfizer.

Piedmont

To kick off DVT Awareness month, the Piedmont Chapter met in Durham, N.C., Feb. 27 for an evening of discussion and case presentations with Victor Tapson, MD from Duke University. SHM members representing six regional hospitalist programs shared their clinical experiences and approach to DVT and pulmonary embolisms as Dr. Tapson presented vignettes that illustrated clinical pearls and best practices in the prevention and treatment of these conditions. Attendees expressed interest in having another chapter event this spring.

San Diego

On March 7, the San Diego Chapter met at Roy’s of La Jolla. Dr. Greg Seymann of University of California at San Diego, a member of SHM’s Public Policy Committee, presented an informative and thought-provoking lecture regarding the future pay-for-performance initiative for Medicare patients. Following the presentation, “Pay-for-Performance, What Hospitalists Need to Know,” the group had a lively discussion regarding the parameters to be measured and how this will affect hospitalists.

SHM Elects New Members to Board of Directors

Two new members announced; one member re-elected

SHM is pleased to announce the election of Joseph Li, MD, and Mahalakshmi Halasyamani, MD, and the re-election of Patrick Cawley, MD, to its board of directors for terms that began at the SHM Annual Meeting May 23-25 in Dallas.

“One of the strengths that keeps SHM on the cutting edge is the infusion of new talent on the board. SHM is fortunate to have a continued source of hospitalist leaders who willingly share their time and talents to help SHM shape and grow the hospital medicine specialty,” says Larry Wellikson, MD, CEO of SHM.

Each of the newly elected SHM board members comes from distinguished programs and institutions.

Dr. Li

Dr. Li is the director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and an assistant professor of medicine at the Harvard Medical School. He has been an active member of SHM, serving on the Education and Annual Meeting Committees, as well as the Procedures Task Force. Dr. Li earned his bachelor’s degree in pharmacy at the University of Oklahoma College of Pharmacy and his medical degree at the University of Oklahoma College of Medicine. He completed his residency at the Beth Israel Deaconess Medical Center.

Dr. Cawley

Dr. Cawley is executive medical director at the Medical University Hospital of South Carolina. Prior to this, he was chief of staff at Conway Medical Center, S.C. He has served on the SHM board of directors since 2004 and is its treasurer. As an active member of SHM, he serves on the Public Policy Committee, Leadership Task Force, and on the advisory board for the Practice Management and Coding Courses. Dr. Cawley earned his bachelor’s degree in biology and chemistry from the University of Scranton (Penn.) and his medical degree from Georgetown University School of Medicine in Wash., D.C. He completed his residency at the Duke University Medical Center in Durham, N.C.

Dr. Halasyamani

Dr. Halasyamani is the medical director of the heart failure program at Saint Joseph Mercy Hospital in Ann Arbor, Mich. Before that, she served as director of academic internal medicine inpatient services. She is also a clinical instructor of internal medicine at the University of Michigan and associate chair of the department of internal medicine at Saint Joseph Mercy Hospital. Dr. Halasyamani earned her bachelor’s degree in English and chemistry from Saint Louis University (Mo.) and her medical degree from Harvard Medical School, Boston. She completed her residency at Brigham and Women’s Hospital.

Congratulations to the newest members of the SHM Board of Directors.

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