Measuring and driving hospitalist value: Expanding beyond wRVUs

The Rarest and Purest Form of Generosity: Simone Weil's Attention and Medical Practice

Attention is essential to the practice of medicine. It is required for expert and timely diagnoses and treatments, is implicated in the techniques and practices oriented toward healing, and enlivens the interpersonal dimensions of care. Attention enables witnessing, presence, compassion, and discernment. The French philosopher and activist Simone Weil (1909-1943) developed one of the most original and important descriptions of attention in the last century. For Weil, attention is not an attitude of strained focus but of perceptive waiting that leads to the acquisition and integration of knowledge. Contrary to activities often foregrounded in clinical medicine, it requires renunciation of the will, gentle directedness toward the origin of actions, and diminishment of the self. This paper critically examines Weil's concept of attention as it applies to health systems, technical/intellectual work, and interpersonal care, as well as its connection to theology, and considers whether attention might find a home within the contemporary clinic.

The development and pilot of a novel mobile application to assess clinician perception of workload and work environment

BACKGROUND

Traditional measures of workload such as wRVUs may not be adequate to understand the impact of workload on key outcomes.

OBJECTIVE

The objective of this study was to develop a mobile application to assess, in near real time, clinicians' perception of workload and work environment.

DESIGNS, SETTINGS AND PARTICIPANTS

We developed the GrittyWork™ application (GW App) using the Chokshi and Mann process model for user-centered digital development. Study occured at a single academic medical center with hospitalist clinicians.

MAIN OUTCOME MEASURES AND MEASURES

Measures included the System Usability Scale (SUS), use measures from GW App, electronic health record (EHR) event log data and note counts, and qualitative interviews.

RESULTS

From October 28, 2022 to November 3, 2022, six hospitalist clinicians provided feedback on the early prototype of the GW App, and from February 28, 2023 to June 8, 2023, 30 hospitalist clinicians participated in the pilot while on clinical service. All 30 clinicians (100%) participated in the pilot submitting data for a total of 122 shifts. Participants reported working 10 ± 1 h per day (mean ± SD) and were responsible for an average of 11 ± 3 patients per day. The postpilot evaluation of the GW App showed a SUS score of 86 ± 11 and a participant preference toward mobile application-based surveys (73% of participants). Regarding workload measures, EHR event log data and notes data correlated with physician-reported workloads. Applying user-centered design techniques, we successfully developed a mobile application with high usability. These data can be paired with EHR event log data and outcomes to provide insights into the impact of workloads and work environments on outcomes.

Characterizing electronic messaging use among hospitalists and its association with patient volumes

BACKGROUND

Secure electronic messaging is increasingly being utilized for communications in healthcare settings. While it likely increases efficiency, it has also been associated with interruptions, high message volumes, and risk of errors due to multitasking.

OBJECTIVES

We aimed to characterize patterns of secure messaging among hospitalists to understand the volume of messages, message patterns, and impact on hospitalist workload.

METHODS

This was a retrospective cross-sectional study of Epic Secure Chat secure electronic messages received and sent by hospitalists from April 1 to April 30, 2023 at a large academic medical center. Number of conversations per day, number of chats sent and accessed per hour, and average minutes between when a chat was sent and accessed (lag time) were analyzed using a Pearson correlation coefficient test. Measures were plotted against patient volume and time of day.

RESULTS

Hospitalists sent or received an average of 130 messages per day with an average of 13 messages sent or received per hour. The median lag time was 39 s. There was a statistically significant correlation between hospital medicine morning census and number of conversations per day, number of chats sent per hour, and number of chats accessed per hour, but census did not impact lag time.

CONCLUSION

Secure messaging volumes may be higher than previously reported, which may affect hospitalist workload and workflow and have unintended effects on interruptions, multitasking, and medical errors. Additional work should be done to better understand local messaging patterns and opportunities to optimize volume of work and distractions.

Standardizing Generalist Definitions to Improve Evidence in General Medicine: Addressing Diverse Interpretations and Lack of Consistency

Purpose

There has been growing interest in generalists in Japan in recent years. However, due to the diverse use of the term "generalist", the specific roles of these physicians remain ambiguous. Consequently, the target population for research on generalists is unclear, making it challenging to conduct studies within the generalist practice framework. Therefore, a literature search was conducted to examine how generalists are defined and classified in research worldwide.

Methods

We conducted a literature search that focused exclusively on articles written in English and used keywords related to generalists, general medicine (GM), primary care, and family medicine. Based on the results, six physicians working in GM reviewed the findings and discussed the identified issues and their potential solutions.

Results

The definition of generalists in studies targeting GM, family medicine, and primary care conducted worldwide, including Japan, varies. Generalists exhibit diverse roles even within university hospitals in Japan. No studies provide a precise categorization or definition of generalists based on specific medical practices or roles, except for hospitalists, who are primarily involved in inpatient management in the United States.

Conclusion

The definition of GM was unclear based on the results of the literature search, and the lack of uniformity in backgrounds has rendered the target population unclear. Consequently, in healthcare settings where medical systems vary by country or region, evidence from studies targeting generalists cannot readily apply to actual practice. Clarifying generalists through an explicit definition based on clinical practice will allow for a more precise target population for research on generalists and enable the accumulation of evidence related to well-defined groups of generalists, contributing to the advancement of GM. Therefore, future research is required to develop new indicators to precisely classify and define generalists.

Attention Among Health Care Professionals : A Scoping Review

BACKGROUND

The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors.

PURPOSE

To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts.

DATA SOURCES

Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024.

STUDY SELECTION

English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction.

DATA EXTRACTION

Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used.

DATA SYNTHESIS

Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention.

LIMITATIONS

Does not synthesize answers to specific questions. Quality of studies was not assessed.

CONCLUSION

This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention.

PRIMARY FUNDING SOURCE

None.

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study

BACKGROUND

Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit.

OBJECTIVE

To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization.

DESIGN, SETTING AND PARTICIPANTS

We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups.

RESULTS

Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction.

CONCLUSIONS

Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

Assessing the contribution of hospital medicine patients to the tertiary quaternary care mission of an academic medical center

Academic medical centers must balance caring for patients in their community with their role as referral centers for more profitable tertiary quaternary (T/Q) care. Hospital medicine services, which admit patients largely from the emergency department, often have the lowest proportion of T/Q care and may thus be under pressure to demonstrate their value to the health system. Looking at the 5771 patients that were discharged from our hospital medicine service between 2021 and 2022, we found that three quarters (74.6%) of patients had at least one prior outpatient encounter at our institution, and that more than a third (36.1%) were established patients in departments of strategic importance to our institution. Our study provides a framework for academic hospital medicine services looking to assess their patient population's connection with the broader health system and suggests that our hospital medicine service provides inpatient care to a population critical to the role of the institution in our community both locally and regionally.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.