Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.

Clinical question: Does delirium contribute to chance of death?

Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.

Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.

Setting: Single ICU in the Netherlands.

Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.

In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.

Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.

Citations: Klouwenberg PM, Zaal IJ, Spitoni C, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. BMJ. 2014;349:g6652. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.

Clinical question: Does delirium contribute to chance of death?

Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.

Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.

Setting: Single ICU in the Netherlands.

Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.

In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.

Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.

Citations: Klouwenberg PM, Zaal IJ, Spitoni C, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. BMJ. 2014;349:g6652. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.

Clinical question: Does delirium contribute to chance of death?

Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.

Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.

Setting: Single ICU in the Netherlands.

Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.

In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.

Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.

Citations: Klouwenberg PM, Zaal IJ, Spitoni C, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. BMJ. 2014;349:g6652. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-922.

In 2012, SHM reported increasing numbers of hospital encounters coded for high-level evaluation and management services, as reported by the 2012 State of Hospital Medicine (SOHM) survey respondents. The 2014 SOHM report shows a solid continuation of this trend, with high-level CPT codes predominating in admission and discharge services by wider margins than ever before.

The 2014 report provides CPT code data from 173 hospitalist groups, who reported the number of inpatient admissions with CPT codes corresponding to Level 1, Level 2, or Level 3. Inpatient discharges have codes corresponding to either Level 1 or Level 2.

Compared to 2012, Level 3 admissions (CPT 99223) increased by 14% in 2014 and now account for 77% of all admissions (see Figure 1). Level 2 discharges (CPT 99239) have increased by 17% since 2012 and now account for 63% of discharges.

In 2014, SOHM added CPT code distribution data for observation care. Observation admissions and inpatient and observation subsequent care are also reported as Level 1, 2, or 3 by the corresponding CPT codes. Observation discharges, which have only one code level, are also reported, in addition to the three levels of same-day admit/discharge encounters.

The rate of Level 3 CPT codes reported for observation admissions, which was 72%, roughly approximated that of inpatient admissions. For subsequent care, Level 2 accounts for the majority of both observation and inpatient codes.

Despite the general predominance of Level 3 admissions and now Level 2 inpatient discharges, not all hospitalist groups deal equally in these higher billing evaluation and management services. Groups in the West region previously dominated the high-level encounters in both admissions and discharges; in 2014, the South took the lead in high-level admissions.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing.–Dr.Creamer

One factor that has consistently signaled lower rates of high-level coding, however, is academic status. A likely reason, as alluded to in a previous “Survey Insights” column, relates to the fact that residents’ time is not billable. This is particularly important in the discharge coding, in which the higher Level 2 code is strictly based on the statement by an attending that discharge services were personally provided for more than 30 minutes. Understandably, this happens less often when a resident’s education includes providing discharge services.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing. This assumes that academic groups are not treating far fewer sick patients, less comprehensively, across the board.

In my own public academic hospital, I see reviewing the required elements of the history and physical examination (H&P) as survival for our hospital and our mission, as well as an opportunity to educate residents simultaneously in patient interviewing skills and system-based practice.

But before I get too far into waxing altruistic, let me recognize another factor suggested by the SOHM report: I am not 100% salaried. That means thorough documentation and accurate coding directly impact my personal compensation.

The 2014 SOHM report shows, as it did in 2012, an inverse correlation between high-level admissions and percent salaried compensation. Although this relationship remains less clear in follow-ups and discharges, perhaps hospitalists pay more attention to coding criteria when it’s bread on the table…and if time permits.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

In 2012, SHM reported increasing numbers of hospital encounters coded for high-level evaluation and management services, as reported by the 2012 State of Hospital Medicine (SOHM) survey respondents. The 2014 SOHM report shows a solid continuation of this trend, with high-level CPT codes predominating in admission and discharge services by wider margins than ever before.

The 2014 report provides CPT code data from 173 hospitalist groups, who reported the number of inpatient admissions with CPT codes corresponding to Level 1, Level 2, or Level 3. Inpatient discharges have codes corresponding to either Level 1 or Level 2.

Compared to 2012, Level 3 admissions (CPT 99223) increased by 14% in 2014 and now account for 77% of all admissions (see Figure 1). Level 2 discharges (CPT 99239) have increased by 17% since 2012 and now account for 63% of discharges.

In 2014, SOHM added CPT code distribution data for observation care. Observation admissions and inpatient and observation subsequent care are also reported as Level 1, 2, or 3 by the corresponding CPT codes. Observation discharges, which have only one code level, are also reported, in addition to the three levels of same-day admit/discharge encounters.

The rate of Level 3 CPT codes reported for observation admissions, which was 72%, roughly approximated that of inpatient admissions. For subsequent care, Level 2 accounts for the majority of both observation and inpatient codes.

Despite the general predominance of Level 3 admissions and now Level 2 inpatient discharges, not all hospitalist groups deal equally in these higher billing evaluation and management services. Groups in the West region previously dominated the high-level encounters in both admissions and discharges; in 2014, the South took the lead in high-level admissions.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing.–Dr.Creamer

One factor that has consistently signaled lower rates of high-level coding, however, is academic status. A likely reason, as alluded to in a previous “Survey Insights” column, relates to the fact that residents’ time is not billable. This is particularly important in the discharge coding, in which the higher Level 2 code is strictly based on the statement by an attending that discharge services were personally provided for more than 30 minutes. Understandably, this happens less often when a resident’s education includes providing discharge services.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing. This assumes that academic groups are not treating far fewer sick patients, less comprehensively, across the board.

In my own public academic hospital, I see reviewing the required elements of the history and physical examination (H&P) as survival for our hospital and our mission, as well as an opportunity to educate residents simultaneously in patient interviewing skills and system-based practice.

But before I get too far into waxing altruistic, let me recognize another factor suggested by the SOHM report: I am not 100% salaried. That means thorough documentation and accurate coding directly impact my personal compensation.

The 2014 SOHM report shows, as it did in 2012, an inverse correlation between high-level admissions and percent salaried compensation. Although this relationship remains less clear in follow-ups and discharges, perhaps hospitalists pay more attention to coding criteria when it’s bread on the table…and if time permits.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

In 2012, SHM reported increasing numbers of hospital encounters coded for high-level evaluation and management services, as reported by the 2012 State of Hospital Medicine (SOHM) survey respondents. The 2014 SOHM report shows a solid continuation of this trend, with high-level CPT codes predominating in admission and discharge services by wider margins than ever before.

The 2014 report provides CPT code data from 173 hospitalist groups, who reported the number of inpatient admissions with CPT codes corresponding to Level 1, Level 2, or Level 3. Inpatient discharges have codes corresponding to either Level 1 or Level 2.

Compared to 2012, Level 3 admissions (CPT 99223) increased by 14% in 2014 and now account for 77% of all admissions (see Figure 1). Level 2 discharges (CPT 99239) have increased by 17% since 2012 and now account for 63% of discharges.

In 2014, SOHM added CPT code distribution data for observation care. Observation admissions and inpatient and observation subsequent care are also reported as Level 1, 2, or 3 by the corresponding CPT codes. Observation discharges, which have only one code level, are also reported, in addition to the three levels of same-day admit/discharge encounters.

The rate of Level 3 CPT codes reported for observation admissions, which was 72%, roughly approximated that of inpatient admissions. For subsequent care, Level 2 accounts for the majority of both observation and inpatient codes.

Despite the general predominance of Level 3 admissions and now Level 2 inpatient discharges, not all hospitalist groups deal equally in these higher billing evaluation and management services. Groups in the West region previously dominated the high-level encounters in both admissions and discharges; in 2014, the South took the lead in high-level admissions.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing.–Dr.Creamer

One factor that has consistently signaled lower rates of high-level coding, however, is academic status. A likely reason, as alluded to in a previous “Survey Insights” column, relates to the fact that residents’ time is not billable. This is particularly important in the discharge coding, in which the higher Level 2 code is strictly based on the statement by an attending that discharge services were personally provided for more than 30 minutes. Understandably, this happens less often when a resident’s education includes providing discharge services.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing. This assumes that academic groups are not treating far fewer sick patients, less comprehensively, across the board.

In my own public academic hospital, I see reviewing the required elements of the history and physical examination (H&P) as survival for our hospital and our mission, as well as an opportunity to educate residents simultaneously in patient interviewing skills and system-based practice.

But before I get too far into waxing altruistic, let me recognize another factor suggested by the SOHM report: I am not 100% salaried. That means thorough documentation and accurate coding directly impact my personal compensation.

The 2014 SOHM report shows, as it did in 2012, an inverse correlation between high-level admissions and percent salaried compensation. Although this relationship remains less clear in follow-ups and discharges, perhaps hospitalists pay more attention to coding criteria when it’s bread on the table…and if time permits.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.

The journey toward patient and family centered care (PFCC) has been one of the hallmarks of early twenty-first century healthcare transformation. The Veterans Health Administration (VHA, including all of its VAMC hospitals) understands the critical importance of PFCC and has fully embraced—indeed, extended—its tenets as a core foundational structure going into the future. As full participants in the collaborative VHA care model, hospitalists and collaborating care teams are enhancing best care/best treatment practices with PFCC modalities.

Transformation is not new to VHA. Starting in the late 1990s, the organization expanded from a hospital-based, specialty care-only institution to one that adopted primary care in a wheel-and-spoke design: a centralized medical center with surrounding community-based primary care clinics. This brought about the infrastructure necessary to create the fully integrated national network that is VHA today. The current PFCC transformation aims to grow VHA a step further by restyling the culture of VHA care to a model that completely focuses the system around the needs of the veterans. VHA’s Blueprint for Excellence, a prescient guiding document for VHA transformation today, explains that the direction to Whole Health encompasses “support for both care needs and health into a coherent experience of veteran-centered care that maximizes well-being.”

The Whole Health program is the sum of patient self-care; personalized, proactive, patient-driven care (PPPDC); and environmental (relationship and community-based) care. The VHA is serious about PFCC: In 2010, the organization created a top-ranking office, aptly named the Office of Patient-Centered Care & Cultural Transformation (OPCC&CT); the office reports directly to national leadership and has as its founding objective the support of this latest transformation.

The VHA’s ambitious adoption of PFCC and the Whole Health program involves fully embracing PPPDC. VHA partners work with each veteran to create a personal health plan (PHP), supported by health coaching, motivational interviewing, and other clinical tools, as a living document aimed at optimizing health and well-being; best practice, evidence-based disease intervention and management provide the chronic and acute care needs.

A veteran’s PHP, essentially a mission and goal-planning document, is founded on what matters most to the veteran and on the aspects of the veteran’s health that are keeping him or her from meeting current and future life goals. Hospitalist providers, including those at VHA, academic, and private sector hospitals, can use the essence of the PHP to guide inpatient care. It is powerful to ask each of our patients what matters most to him or her, to understand a patient’s situational life goal. To partner with patients, helping each one to focus on and realize a pressing individual goal, not only centers us but humanizes an often destabilizing and stressful time for our patients.

Hippocrates is quoted as saying that we “cure sometimes, treat often, and comfort always.” This is true today. We rarely cure, but we can offer treatment with maximal comfort during a hospitalization, assisting our patients in returning to the health they had established prior to their admission. Hospital medicine providers and hospital-based teams act as a safety net, caring for our acutely ill patients, working with them to bring them back to their baseline, and getting them back on track to be able to enjoy what really matters to them, their “mission” at the moment. PFCC and PPPDC provide the culture and tools to meet our patients’ goals.

The VHA’s number one strategic goal has been to provide veterans PPPDC. Hospitalists and hospitals have adopted—and will continue to adopt—practices that move toward this goal. PFCC is at its essence patient empowerment, and its primary benefits are enhancement of patient safety, quality of care, and patient satisfaction. PFCC is one innovation necessary to reach the “triple aim” all healthcare systems strive toward: better health, better care, better value.

Dr. Steinbach is chief of hospital medicine at the Atlanta VAMC and assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine in Atlanta.

This month, Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California San Francisco Medical Center and well known for his work in patient safety and healthcare quality, debuts his latest book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. The book explores the realities of U.S. efforts to bring healthcare into the digital age.

Dr. Wachter is especially concerned with the consequences—both intended and unintended—of health information technology. The Hospitalist spoke with Dr. Wachter about why he wrote the book and asked him about some of the burning issues facing hospitalists today.

Question: In the book’s introduction, you state that while computers are preventing medical errors, they are also causing new kinds of mistakes. One was a case at your hospital in which an adolescent was given a 39-fold overdose of a routine antibiotic. What was it about this case that galvanized you to write the book?

Answer: A few weeks after the error, I attended the root cause analysis, and my jaw just fell and fell. I was struck by the disconnect between what we’d been saying for years—‘When we finally get computers, we’re going to fix so many of these problems’—and the reality, that in about as wired an environment as you can imagine, we managed to give a kid 40 pills. [The patient had a seizure but survived.] Clearly, the case was partly about a glitchy computer system. But the larger problems related to the troubling people-computer interfaces. That’s what I wanted to address in the book.

Q: How did you secure buy-in from the hospital, the involved providers, and the family to write about the case?

A: In 2004, I wrote a book, Internal Bleeding, in which we presented many cases of medical mistakes, some of them fatal. We managed to keep the cases anonymous, and from this and similar projects, I developed a reputation for doing this kind of thing diplomatically and carefully. I think that’s why the risk manager didn’t reject the idea out of hand, and, ultimately, my CMO and CEO agreed to it as well. After that, I approached the involved clinicians and the patient and his mother. To everyone’s credit—the providers, the administrators, and the patient and family—they believed that this case was so important that we should be open and honest about it. My experience is that people are sometimes trying to find some meaning in a horrible event, and that meaning can come from helping to prevent a similar case in the future.

In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers.

Q: What are some of the tensions that affect the interface between frontline providers and healthcare IT?

A: In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers. There is a powerful concept known as “adaptive change,” as contrasted with technical change. Technical change is like a cookbook: Put in a set of rules, have people follow them, and everything works out fine. Adaptive change is more complex and subtle; it requires the intense involvement of frontline workers.

We made the mistake of treating health IT as technical change, but it is probably the hardest adaptive change we’ve ever tried. My goal was to create a national conversation about this, which is what we need if we’re going to get it right.

Gretchen Henkel is a freelance writer in California.

This month, Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California San Francisco Medical Center and well known for his work in patient safety and healthcare quality, debuts his latest book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. The book explores the realities of U.S. efforts to bring healthcare into the digital age.

Dr. Wachter is especially concerned with the consequences—both intended and unintended—of health information technology. The Hospitalist spoke with Dr. Wachter about why he wrote the book and asked him about some of the burning issues facing hospitalists today.

Question: In the book’s introduction, you state that while computers are preventing medical errors, they are also causing new kinds of mistakes. One was a case at your hospital in which an adolescent was given a 39-fold overdose of a routine antibiotic. What was it about this case that galvanized you to write the book?

Answer: A few weeks after the error, I attended the root cause analysis, and my jaw just fell and fell. I was struck by the disconnect between what we’d been saying for years—‘When we finally get computers, we’re going to fix so many of these problems’—and the reality, that in about as wired an environment as you can imagine, we managed to give a kid 40 pills. [The patient had a seizure but survived.] Clearly, the case was partly about a glitchy computer system. But the larger problems related to the troubling people-computer interfaces. That’s what I wanted to address in the book.

Q: How did you secure buy-in from the hospital, the involved providers, and the family to write about the case?

A: In 2004, I wrote a book, Internal Bleeding, in which we presented many cases of medical mistakes, some of them fatal. We managed to keep the cases anonymous, and from this and similar projects, I developed a reputation for doing this kind of thing diplomatically and carefully. I think that’s why the risk manager didn’t reject the idea out of hand, and, ultimately, my CMO and CEO agreed to it as well. After that, I approached the involved clinicians and the patient and his mother. To everyone’s credit—the providers, the administrators, and the patient and family—they believed that this case was so important that we should be open and honest about it. My experience is that people are sometimes trying to find some meaning in a horrible event, and that meaning can come from helping to prevent a similar case in the future.

In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers.

Q: What are some of the tensions that affect the interface between frontline providers and healthcare IT?

A: In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers. There is a powerful concept known as “adaptive change,” as contrasted with technical change. Technical change is like a cookbook: Put in a set of rules, have people follow them, and everything works out fine. Adaptive change is more complex and subtle; it requires the intense involvement of frontline workers.

We made the mistake of treating health IT as technical change, but it is probably the hardest adaptive change we’ve ever tried. My goal was to create a national conversation about this, which is what we need if we’re going to get it right.

Gretchen Henkel is a freelance writer in California.

This month, Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California San Francisco Medical Center and well known for his work in patient safety and healthcare quality, debuts his latest book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. The book explores the realities of U.S. efforts to bring healthcare into the digital age.

Dr. Wachter is especially concerned with the consequences—both intended and unintended—of health information technology. The Hospitalist spoke with Dr. Wachter about why he wrote the book and asked him about some of the burning issues facing hospitalists today.

Question: In the book’s introduction, you state that while computers are preventing medical errors, they are also causing new kinds of mistakes. One was a case at your hospital in which an adolescent was given a 39-fold overdose of a routine antibiotic. What was it about this case that galvanized you to write the book?

Answer: A few weeks after the error, I attended the root cause analysis, and my jaw just fell and fell. I was struck by the disconnect between what we’d been saying for years—‘When we finally get computers, we’re going to fix so many of these problems’—and the reality, that in about as wired an environment as you can imagine, we managed to give a kid 40 pills. [The patient had a seizure but survived.] Clearly, the case was partly about a glitchy computer system. But the larger problems related to the troubling people-computer interfaces. That’s what I wanted to address in the book.

Q: How did you secure buy-in from the hospital, the involved providers, and the family to write about the case?

A: In 2004, I wrote a book, Internal Bleeding, in which we presented many cases of medical mistakes, some of them fatal. We managed to keep the cases anonymous, and from this and similar projects, I developed a reputation for doing this kind of thing diplomatically and carefully. I think that’s why the risk manager didn’t reject the idea out of hand, and, ultimately, my CMO and CEO agreed to it as well. After that, I approached the involved clinicians and the patient and his mother. To everyone’s credit—the providers, the administrators, and the patient and family—they believed that this case was so important that we should be open and honest about it. My experience is that people are sometimes trying to find some meaning in a horrible event, and that meaning can come from helping to prevent a similar case in the future.

In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers.

Q: What are some of the tensions that affect the interface between frontline providers and healthcare IT?

A: In the book, I contrast the way the healthcare IT companies build their systems—with relatively little input from clinicians—with the philosophy at Boeing, where they bring pilots into the process to develop cockpit computers. There is a powerful concept known as “adaptive change,” as contrasted with technical change. Technical change is like a cookbook: Put in a set of rules, have people follow them, and everything works out fine. Adaptive change is more complex and subtle; it requires the intense involvement of frontline workers.

We made the mistake of treating health IT as technical change, but it is probably the hardest adaptive change we’ve ever tried. My goal was to create a national conversation about this, which is what we need if we’re going to get it right.

Gretchen Henkel is a freelance writer in California.