Patient Care

Ultrasound More Common at the Bedside


A recent “Current Concepts” article in the New England Journal of Medicine (2011;364:749) by a pair of Yale University physicians asserts that the day is close at hand when ultrasound interpretations by clinicians at the patient’s bedside will become as routine in hospital care as the trusty stethoscope. Ultrasound, a noninvasive form of imaging related to oceanographic sonar, has moved beyond its traditional home in radiology to myriad other medical specialties and practice areas. The technology has become smaller, less expensive, and higher in resolution in recent years, the authors note, adding that it has been used on Mount Everest and the international space station, as well as in battlefield situations.

“It’s becoming more accessible, and more training is available to physicians who aren’t radiologists,” says Diane Sliwka, MD, a hospitalist at the University of California at San Francisco (UCSF).

Dr. Sliwka says the NEJM article represents a milestone in the dissemination of bedside ultrasound. She conducts monthly faculty development training in procedural ultrasound at UCSF, workshops at HM and internal-medicine conferences, and training sessions for other hospitals.

The most common uses for bedside, “point of care” ultrasound include guiding procedures, such as thoracentesis and paracentesis, with improved safety over doing such insertions “blind.” Emerging procedural uses include lumbar puncture and arthrocentesis. Diagnostically, bedside ultrasound can provide quick screening and assessment, for example, of fluid buildup around the heart; previously, it could take hours to get the results from a formal heart study.

As with the stethoscope, Dr. Sliwka says, training in its correct use and scope of appropriate bedside practice is essential: “My advice is to learn from the experts at your facility, including the radiologists, critical care, or emergency physicians.” Ultrasound courses are increasing at hospitalist conferences, but space often is limited, and further supervised practice back home is needed.

The next step for hospitalists could be the definition of appropriate scope of practice, training, and competencies for its use. “Creating a niche in this area can be a nice change of pace from our traditional work as hospitalists,” Dr. Sliwka says. —LB


Video Chat Takes Off for Physicians

Video Chat Takes Off for Physicians

A recent study of digital adoption trends found that 7% of U.S. physicians now use video consultations to communicate with patients.

Manhattan Research’s 2011 “Taking the Pulse” survey of 2,000 physicians’ use of technology found that video chat is emerging as a way to consult with patients about nonurgent issues and follow-up questions or with geographically dispersed patients. Psychiatrists and oncologists are more likely to use the new technology. Doctors’ concerns regarding reimbursement, liability, and HIPAA privacy rules remain barriers to adoption.

For more information, visit—LB


Positive Outcomes from Full Disclosure of Medical Errors

The University of Michigan Health System’s (UMHS) risk-management model of full disclosure with offer of compensation for medical errors sparked hospitalist Allen Kachalia, MD, JD, of Brigham & Women’s Hospital in Boston to retrospectively study the outcomes of malpractice-claims-related performance before and after UMHS implemented the system in 2001.

Among the results Dr. Kachalia reported in his research abstract plenary at HM10, and subsequently published in Annals of Internal Medicine (2010;153(4):213-221), the mean monthly rate of new claims per 100,000 patient contacts decreased 36% after the full-disclosure model was adopted, while the rate of claims resulting in lawsuits declined by 65%. Claims also were resolved more quickly with the full-disclosure model.

Disclosure of medical error, Dr. Kachalia says, means “if someone is injured by medical care caused by medical error, the physician tells the patient they made the error, how it happened, and, often, what they’ll do to fix it.” An apology is somewhat different, he adds, and there’s no generic script for an apology. “What patients want is sincerity,” he says.

How can hospitalists work with full disclosure? “The general advice most institutions give is that when you want to disclose a medical error, first get your risk-management and patient-safety officers involved. They can help during every step of the process of investigating the event and disclosing,” Dr. Kachalia explains. “Assure patients that you are going to look into their concerns. Then make sure that a thorough investigation is done.”—LB

Practice Management

AMA-MGMA Toolkit Sorts Transitional-Care Software Options

HM practices with physicians in outpatient settings—be they discharge clinics or transitional-care centers—don’t always know how to determine the most useful practice-management software for their needs. So for those not helped by informatics staff, consider the new “Practice Management System Software Directory” from AMA and the Medical Group Management Association (MGMA).

The online repository, which launched in May, is a companion to the “Selecting a Practice Management System” toolkit the joint venture unveiled last fall. While the system is geared toward ambulatory-care settings, Robert Tennant, a senior policy advisor with MGMA, says any HM group with practitioners working on transitional care would find it useful.

Overall, the directory’s goal is to guide providers on how to navigate the increasingly complex world of practice-management options as new guidelines for “meaningful use” are defined, as well as new rules governing electronic claims processing. A new claims standard, known as HIPAA version 5010, is going live Jan. 1, 2012, so Tennant believes the directory is timely.

“It’s very difficult, whether in a practice or a hospital, to know the best software to pick,” he says. “There are plenty of vendors out there telling you they’re the best. There’s no easy way to comparison-shop.”

Now physicians can use the toolkit to measure basic functions. The directory, which will be updated on a rolling basis, will catalogue price range (excluding implementation costs), the number of installed customers, the target market for the product, what year the software was first offered, and whether the vendor also offers an electronic health record (EHR) system. That last point is of particular note to hospitalists as a link between practice management and medical records can help make a practice more efficient, Tennant says.

“What we’ve seen,” he adds, “is those that have that seamless integration between practice-management systems and EHR have higher productivity and higher levels of satisfaction.” —RQ

By The Numbers


The average amount of money HM groups received in support per full-time equivalent (FTE) in fiscal year 2010, according to new SHM-MGMA survey data. The data point—the so-called “subsidy”—was first revealed at HM11 in Dallas.

After several years of leveling off at roughly $100,000, some hospitalists say they were surprised to see the figure rise so quickly. The report also shows that 19% of hospitalist practices receive no support, a finding that prompted new SHM President Joseph Li, MD, SFHM, to ask: “Are we looking at two business models or two care models?”—RQ

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