Francisco Alvarez
1. I enjoyed your 2017 PHM talk “Little People, Big Drugs: Pediatric Medication Safety in Adult Settings,” as well as the Hospital Pediatrics article looking at the same topic (Hosp Pediatr. 2016 Dec;6(12):744-749). In the talk, you spoke about the specific challenges associated with medication errors in children with weight based dosing, standardized code carts, and order sets. What do you think are some of the biggest safety changes that need to be evaluated or made in hospital settings that care for pediatric and adult patients?
From a broad perspective the main challenge is the understanding of the nuances of pediatric medication safety practices that make it different from adults. For example, most adult medications are standard doses regardless of weight. Pediatric medications are not only weight based but also in certain circumstances (like NICU population) volume and hence concentrations are another factor that have to be accounted for. Contraindicated medications for certain age groups is another issue which tends to be overlooked and leads to many medications that are commonly used in adults to be used in pediatric patients (ex. Codeine or Dextromethorphan for cough). General emergency departments are the most challenging when it comes to maintaining and developing a pediatric medication safety infrastructure. The high volume, turnover, and acuity of many general emergency departments tends to not only lead to many of the oversights mentioned, but also increases the probability of a medication error. With all of that as background the main changes are to develop a team or group with the clear understanding of the above challenges and to build recommendations around those. These can be things such as pediatric specific order sets and/or weight based standardized dosages to more robust pediatric specific care areas that limit adult hybrid medications or orders. My favorite statement when it comes to safety has been “make it easy to do the right thing, and hard to do the wrong thing”, which can be used when developing any process that minimizes medication errors.
2. High Value Care is an increasingly popular topic among hospitalists and an interest of yours. Many of us struggle to incorporate this into resident education, to discuss it with families, and to mention it to colleagues (specifically nursing, RTs, and specialists). How do you approach it and integrate it into your clinical work?
My approach to this topic highly depends on the audience. I tend to give the general big picture lecture to most, but try to make it as relevant and practical to the individual I am speaking to. For example, decreasing length of stay by implementing best practices is a metric many people look at. For residents, have them clarify how adding a study or lab would improve outcome or change management. I add the family perspective, reminding them that this may cause them to stay extra hours or days (which for hourly waged families can be a significant financial burden). For other providers length of stay is better approached from the overall cost for which the financial value becomes significant on justifying their existence and “value” to the hospital system. By understating how the hospital is paid/reimbursed by insures they can better align their administration level conversations, which may become less about volume and more about cost per patient or decreasing readmissions to hospital (ex. Bundled and Capitation models respectively).
3. Along the same lines, you authored a paper in December 2015 in Hospital Pediatrics entitled, “The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital.” In the paper, evidence-based order sets and asthma pathway were used to reduce use of bronchodilators and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011. What were the keys to the success of these measures? With the order sets, you were able to reduce length of stay in bronchiolitis and asthma, but not pneumonia – any idea why?
One of the most important things that I learned very quickly is not to lead as a single group but as an organizational team. For that I cannot emphasize enough the need of a nursing champion at a minimum, but ideally a champion in each area that may affected (even one that is sometimes overlooked like Pharmacy). It not only takes away some of the labor on developing and implementing, but it is seen as a multi-disciplinary concern and issue not just a “hospitalist agenda”.
As far as the difference in length of stay when we implemented the asthma, bronchiolitis, and pneumonia order sets, we believed based on this single site study that the main reason for the lack of difference in the length of stay for pneumonia as opposed to asthma and bronchiolitis was that their wasn’t that much of a difference on what the physicians were doing on a day to day or hourly basis. For example the asthma and bronchiolitis order sets had albuterol as part of the management. In the asthma order set it had an asthma score that clearly defined acuity which limited the variability of transitioning from continuous to every 4 hours; hence able to decrease length of stay variances. In the bronchiolitis order set, the removal of albuterol as standard therapy removed the previous use of a response to albuterol and weaning necessity from defining readiness for discharge. These were key factors that were not part of the pneumonia management since antibiotic determination and oxygen requirement had minimal variation or capacity to adjust dramatically.
4. I attended your 2016 PHM talk, “Show Me the Money! Adjusting to the Market: The Business Behind Hospitalist Medicine” (available here on SOHM: http://www.sohmlibrary.org/phm-2016.html). During the talk, you had participants try to match terms like “fee for service,” “capitation,” and “DRG” and my table was struggling. How can we as hospitalists better educate ourselves on this critical topic?
Besides going to a PHM conference talk? 😊 One starting point would be to touch base with your program director or chief and ask them what they think of in regards to the hospital/program finances and why? They have some insight on why they are being asked for certain things and would have looked into how to align their program to the hospital. Other venues are the adult hospitalists within your institutions and/or via Society of Hospital Medicine (SHM) conferences and on-line sources. The adult hospitalists have been going through the financial transformation over the past 10-15 years that the pediatric hospitalists are now starting to see. They have an extensive amount of knowledge to share for which SHM has been providing for them around the same amount of time. For others who want more in depth knowledge I would recommend sources like Centers for Medicare & Medicaid Services (CMS), Advisory Board (can usually get membership granted via your institution), and Morning Consult (although this is more political but keeps you abreast of current federal and state changes).
5. In that same talk, you spoke about what value a hospitalist can provide, such as decreasing use of unnecessary medications or Press Ganey (or CHCAHPS) Scores. I think many hospitalist groups struggle with justifying their salaries or new hires to the hospital or medical schools that employ them. What advice do you have in those cases? What should you look for or what questions should you ask regarding reimbursement/pay if you are seeking out a new job?
This may be somewhat similar to my answer to Question # 2. In order to show your “value” to the institution you have to first know what they care about and their “pain points.” Although when hired through a medical school the value may be measured through academic work and that may be the clearest direct demonstration in that venue, all physicians, directly or indirectly, are paid by the hospital system that cares for the patients. The reason I state that is that in order to align your care practices and/or priorities one must know: 1. How the hospital is paid (by individual insures and what percentage from each one; i.e. payor mix)? 2. Where are they losing money and/or struggling? 3. How the demographics and/or insurance landscape is changing for them over the next 3-5 years (they would give some insight into this during town hall meetings or Grand Rounds)? Knowing these 3 questions will help hospitalists better align their current projects and conversations to coming up with solutions for them. At a minimum it will make administration aware that you understand and are part of the team working on solutions, which is significantly valuable to them.
As far as questions to ask around reimbursement and pay when seeking a new job, I would focus on demonstrating and objectively stating what you will bring beyond your clinical skills (which is the baseline entry point for all hires). That may give you some wiggle room within they pay scales that most organizations have, which may only be extra educational stipend, administrative time support, etc.. that most directors have influence over. But, on a more philosophical note, I would highly recommend to really look if the job and program fit your personality, ethics, and long term goals regardless of salary. Nothing wrong with the extra money, but being miserable may be the “cost of living” variable that you want to account for.
6. In 2017, you gave a talk at PHM regarding telemedicine within Maryland and Virginia programs, some of the hospitalists provide telemedicine at rural hospitals. For those of us unfamiliar with telemedicine, how does this work and what types of consultation/advice is provided? What advice do you have for those looking to implement this?
The most basic telemedicine that many sites provide are echocardiograms, EEG’s, and radiology. These are basically set up as information packets sent to consultants (either affiliated with staff or independent contractors) for which they review and give you their impressions and/or recommendations. One of the main things for these is the need for a local technician to do the study appropriately. These are generally trained by the receiving entity if local training was not already available.
The more robust telemedicine programs are those that provide real time video-teleconferencing, diagnostic tools (i.e. stethoscopes, dermascopes, ophthalmoscopes, etc..) that the provider on the other end can use during the consultation via a local provider or technician. These require a firm infrastructure and designated area and/or equipment to be used. Also, a more significant initial and sustainable financial investment to start and continue.
Regardless of which of the latter two are being looked into starting. The question has to be if this is a novel tool to start a new service line that was not available before, or to augment a service or need that the hospital already has? Ideally, you want to aim for the latter since starting or promoting a new service is a significantly more challenging thing to do and the motto “if you build it, they will come” does not always hold true.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
As physicians, we all entered into the study medicine to care for our fellow man. We continue to struggle with a paradoxical system that is more focused on “making sick patients healthy” and not “keeping patients healthy.” Imagining a world where we get so good at the latter that hospitals become smaller and volumes decrease is something that we dread to think of. Since if that came to pass our jobs and finances would cease to exist. As the future continues to evolve we as hospitalists should not limit ourselves to what we can do within the constraints of our hospital systems. To see our role as healthcare innovators for improving health, not just caring for the sick, within all of the paths of life that our patients and families walk.
From a broad perspective the main challenge is the understanding of the nuances of pediatric medication safety practices that make it different from adults. For example, most adult medications are standard doses regardless of weight. Pediatric medications are not only weight based but also in certain circumstances (like NICU population) volume and hence concentrations are another factor that have to be accounted for. Contraindicated medications for certain age groups is another issue which tends to be overlooked and leads to many medications that are commonly used in adults to be used in pediatric patients (ex. Codeine or Dextromethorphan for cough). General emergency departments are the most challenging when it comes to maintaining and developing a pediatric medication safety infrastructure. The high volume, turnover, and acuity of many general emergency departments tends to not only lead to many of the oversights mentioned, but also increases the probability of a medication error. With all of that as background the main changes are to develop a team or group with the clear understanding of the above challenges and to build recommendations around those. These can be things such as pediatric specific order sets and/or weight based standardized dosages to more robust pediatric specific care areas that limit adult hybrid medications or orders. My favorite statement when it comes to safety has been “make it easy to do the right thing, and hard to do the wrong thing”, which can be used when developing any process that minimizes medication errors.
2. High Value Care is an increasingly popular topic among hospitalists and an interest of yours. Many of us struggle to incorporate this into resident education, to discuss it with families, and to mention it to colleagues (specifically nursing, RTs, and specialists). How do you approach it and integrate it into your clinical work?
My approach to this topic highly depends on the audience. I tend to give the general big picture lecture to most, but try to make it as relevant and practical to the individual I am speaking to. For example, decreasing length of stay by implementing best practices is a metric many people look at. For residents, have them clarify how adding a study or lab would improve outcome or change management. I add the family perspective, reminding them that this may cause them to stay extra hours or days (which for hourly waged families can be a significant financial burden). For other providers length of stay is better approached from the overall cost for which the financial value becomes significant on justifying their existence and “value” to the hospital system. By understating how the hospital is paid/reimbursed by insures they can better align their administration level conversations, which may become less about volume and more about cost per patient or decreasing readmissions to hospital (ex. Bundled and Capitation models respectively).
3. Along the same lines, you authored a paper in December 2015 in Hospital Pediatrics entitled, “The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital.” In the paper, evidence-based order sets and asthma pathway were used to reduce use of bronchodilators and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011. What were the keys to the success of these measures? With the order sets, you were able to reduce length of stay in bronchiolitis and asthma, but not pneumonia – any idea why?
One of the most important things that I learned very quickly is not to lead as a single group but as an organizational team. For that I cannot emphasize enough the need of a nursing champion at a minimum, but ideally a champion in each area that may affected (even one that is sometimes overlooked like Pharmacy). It not only takes away some of the labor on developing and implementing, but it is seen as a multi-disciplinary concern and issue not just a “hospitalist agenda”.
As far as the difference in length of stay when we implemented the asthma, bronchiolitis, and pneumonia order sets, we believed based on this single site study that the main reason for the lack of difference in the length of stay for pneumonia as opposed to asthma and bronchiolitis was that their wasn’t that much of a difference on what the physicians were doing on a day to day or hourly basis. For example the asthma and bronchiolitis order sets had albuterol as part of the management. In the asthma order set it had an asthma score that clearly defined acuity which limited the variability of transitioning from continuous to every 4 hours; hence able to decrease length of stay variances. In the bronchiolitis order set, the removal of albuterol as standard therapy removed the previous use of a response to albuterol and weaning necessity from defining readiness for discharge. These were key factors that were not part of the pneumonia management since antibiotic determination and oxygen requirement had minimal variation or capacity to adjust dramatically.
4. I attended your 2016 PHM talk, “Show Me the Money! Adjusting to the Market: The Business Behind Hospitalist Medicine” (available here on SOHM: http://www.sohmlibrary.org/phm-2016.html). During the talk, you had participants try to match terms like “fee for service,” “capitation,” and “DRG” and my table was struggling. How can we as hospitalists better educate ourselves on this critical topic?
Besides going to a PHM conference talk? 😊 One starting point would be to touch base with your program director or chief and ask them what they think of in regards to the hospital/program finances and why? They have some insight on why they are being asked for certain things and would have looked into how to align their program to the hospital. Other venues are the adult hospitalists within your institutions and/or via Society of Hospital Medicine (SHM) conferences and on-line sources. The adult hospitalists have been going through the financial transformation over the past 10-15 years that the pediatric hospitalists are now starting to see. They have an extensive amount of knowledge to share for which SHM has been providing for them around the same amount of time. For others who want more in depth knowledge I would recommend sources like Centers for Medicare & Medicaid Services (CMS), Advisory Board (can usually get membership granted via your institution), and Morning Consult (although this is more political but keeps you abreast of current federal and state changes).
5. In that same talk, you spoke about what value a hospitalist can provide, such as decreasing use of unnecessary medications or Press Ganey (or CHCAHPS) Scores. I think many hospitalist groups struggle with justifying their salaries or new hires to the hospital or medical schools that employ them. What advice do you have in those cases? What should you look for or what questions should you ask regarding reimbursement/pay if you are seeking out a new job?
This may be somewhat similar to my answer to Question # 2. In order to show your “value” to the institution you have to first know what they care about and their “pain points.” Although when hired through a medical school the value may be measured through academic work and that may be the clearest direct demonstration in that venue, all physicians, directly or indirectly, are paid by the hospital system that cares for the patients. The reason I state that is that in order to align your care practices and/or priorities one must know: 1. How the hospital is paid (by individual insures and what percentage from each one; i.e. payor mix)? 2. Where are they losing money and/or struggling? 3. How the demographics and/or insurance landscape is changing for them over the next 3-5 years (they would give some insight into this during town hall meetings or Grand Rounds)? Knowing these 3 questions will help hospitalists better align their current projects and conversations to coming up with solutions for them. At a minimum it will make administration aware that you understand and are part of the team working on solutions, which is significantly valuable to them.
As far as questions to ask around reimbursement and pay when seeking a new job, I would focus on demonstrating and objectively stating what you will bring beyond your clinical skills (which is the baseline entry point for all hires). That may give you some wiggle room within they pay scales that most organizations have, which may only be extra educational stipend, administrative time support, etc.. that most directors have influence over. But, on a more philosophical note, I would highly recommend to really look if the job and program fit your personality, ethics, and long term goals regardless of salary. Nothing wrong with the extra money, but being miserable may be the “cost of living” variable that you want to account for.
6. In 2017, you gave a talk at PHM regarding telemedicine within Maryland and Virginia programs, some of the hospitalists provide telemedicine at rural hospitals. For those of us unfamiliar with telemedicine, how does this work and what types of consultation/advice is provided? What advice do you have for those looking to implement this?
The most basic telemedicine that many sites provide are echocardiograms, EEG’s, and radiology. These are basically set up as information packets sent to consultants (either affiliated with staff or independent contractors) for which they review and give you their impressions and/or recommendations. One of the main things for these is the need for a local technician to do the study appropriately. These are generally trained by the receiving entity if local training was not already available.
The more robust telemedicine programs are those that provide real time video-teleconferencing, diagnostic tools (i.e. stethoscopes, dermascopes, ophthalmoscopes, etc..) that the provider on the other end can use during the consultation via a local provider or technician. These require a firm infrastructure and designated area and/or equipment to be used. Also, a more significant initial and sustainable financial investment to start and continue.
Regardless of which of the latter two are being looked into starting. The question has to be if this is a novel tool to start a new service line that was not available before, or to augment a service or need that the hospital already has? Ideally, you want to aim for the latter since starting or promoting a new service is a significantly more challenging thing to do and the motto “if you build it, they will come” does not always hold true.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
As physicians, we all entered into the study medicine to care for our fellow man. We continue to struggle with a paradoxical system that is more focused on “making sick patients healthy” and not “keeping patients healthy.” Imagining a world where we get so good at the latter that hospitals become smaller and volumes decrease is something that we dread to think of. Since if that came to pass our jobs and finances would cease to exist. As the future continues to evolve we as hospitalists should not limit ourselves to what we can do within the constraints of our hospital systems. To see our role as healthcare innovators for improving health, not just caring for the sick, within all of the paths of life that our patients and families walk.