Hospital Medicine

The field of hospital medicine in the United States has grown rapidly in the past 20 years, from less than 1,000 practicing physicians to more than 44,000 today.  As in-hospital programs continue to develop, there is increasing demand for hospitalists who are eager to practice medicine in a complex and rapidly changing environment. Here, two Atlanta physicians share some of their experiences and insights into the challenges of hospital medicine.

EMR as a game-changer

Larry Bartel, M.D., employed by Kaiser Permanente and Team Lead for the Permanente Hospitalists at  Emory Saint Joseph’s Hospital, says the transition from paper to digital records has been one of the biggest changes in the work of hospitalists to date.

“At Emory Saint Joseph’s, hospitalists are on duty 24/7, 365. We have nocturnists and day doctors, and we have admitters and rounders. It’s a complex system for giving good hospital care. We have volumes of records involved in delivering that care,” he said. “Two years ago, we went from mainly a hybrid paper system at Northside Hospital  to a complete electronic medical record in the Emory network. It was a huge change.”

One of the biggest benefits to using a complete EMR system is interoperability and the availability of information, according to Bartel.

“We can see a lot more about a particular patient now, regardless of where they have been seen in the past, such as labs and other physician’s notes, through electronic health information exchange and through Care Everywhere in Kaiser’s Health Connect EMR.  It’s a huge quality and safety improvement,” he said. “A good example of this is the fantastic advancement of the state’s prescription drug monitoring program (PDMP). The opioid epidemic is troubling. But through the EMR, we can see a patient’s prescribed medications and refills, which helps us make better decisions about their care. Also, we can let the patient know that their refills are transparent; we know what the drug is and who prescribed it.”

Bartel adds that EMR has its pros and its cons, but is happy, overall, with making the leap from paper to digital records. One reason is the improvement of data reporting.

“I find that I’m spending more time on patients, reading through their records, than I did five years ago. But the data we’re getting today is much more useful,” he noted. “Due to the accuracy and amount of data provided through EMR, I often find that patients are much sicker than I would have known in the past. So, I spend more time with them. But ultimately, this benefits patients in quality of care and we can reach the right diagnosis quicker without duplication of testing and consultation.”

COVID presents new challenges in patient care

With the advent of COVID-19 earlier this year, the entire health care industry’s focus became honed in on how to safely deliver care. Although patient censuses decreased during the early months of COVID due to postponement of elective surgeries and general fear of the virus, hospitalists found themselves locked into a new, exhausting regimen of safety protocols that piled on hours and new  stresses to their daily and weekly schedules.

“COVID has changed our job dramatically. When it started in March, there was fear among hospitalists because we didn’t know the status of our PPE from day to day. All you heard about was shortages of equipment and there was hoarding of supplies like masks,” Bartel said. “But now we have knowledge that shows PPE really does work. I believe our hospitals and clinics have done an amazing job in keeping staff and patients safe.  Patients, at first, were avoiding the emergency rooms for their other medical problems such as stroke and heart attack. It was odd to see fewer patients with stroke and heart attack at the beginning of the COVID crisis. I can only surmise that patients with cardiac or neurological conditions were avoiding the emergency rooms. Volume, though, has built up again and the emergency room is a safe place to be evaluated. I believe you are more at risk of contracting COVID out in the community than in the hospitals; we’re more likely to get COVID at the grocery store.”

Bartel adds that patient care has become much more demanding. Just the task of keeping up with one’s personal PPE gear, along with putting it on and taking it off between patients, add a lot of extra steps and time to a hospital physician’s day. But it’s the actual patient treatment and care that has presented the biggest challenges.

“Obviously, we see more people who can go into respiratory distress due to the virus. It’s different from the viral and bacterial pneumonias we normally see. COVID patients seem to go downhill very fast and unpredictably,” he said. “But treatments are improving, such as the introduction of steroids and care protocols, and we are seeing patients getting better.”

Additionally, COVID has presented the difficulty of patients feeling isolated. Hospitals have had to implement no visitation policies in order to keep patients, families and staff safe.

“The lack of visitors is hard, especially for elderly patients who are confused. Having family at their bedside keeps them oriented and from getting delirious. Now, because of COVID policies, they are isolated and have trouble comprehending,” Bartel said. “Also, the families are anxious; their imaginations are going haywire with inaccurate thoughts about their loved one’s care. So now, we are calling families to inform them, which adds on time to our day. Sometimes, these conversations are long because of their anxiety. It has affected our workday efficiency. Our hospitals have tried to use iPads and smartphones to let families see and communicate with their loved ones. It is an amazingly useful technology for this pandemic.”

New efficiencies in hospital medicine improve quality of care

Emilio Lacayo, M.D., who has practiced hospital medicine for the past 23 years, says some new operational protocols are improving quality of care for the patient and delivery of care for physicians.

“A few years ago, in terms of hospital medicine, we had a rotation where physicians would come to the emergency room whenever there was a new admission. So, the hospitalist would be pulled away from rounds to go do the admission. It was very time-consuming,” he said. “But today, larger groups of hospitalists are being divided into two teams, ‘admitters’ and ‘rounders.’ Admitting physicians deal with ER admissions and rounding physicians continue with the flow of seeing patients in the hospital.”

Lacayo adds that the division of responsibilities has vastly improved the workflow for hospitalists.

“In the past, I’ve had to work both sides, admissions and rounds, which makes patient care complicated and time-consuming,” he said. “This dedicated assignment has improved both our efficiency and the quality of care.”

Like many of his colleagues, Lacayo feels that the EMR has caused a significant shift for the better in the practice of hospital medicine.

“At first, I was reluctant to make the shift from paper to electronic records because it was a big change and we would have to learn a new system,” he said. But the reality is, you have all of a patient’s information right there in front of you — you can see the films, cardiac catheterization results, lab reports, etc., all on one screen.”

In addition to being a central repository for patient information from a variety of sources, the EMR has contributed significantly to improvements in continuity of care. Lacayo points to transfer of patient care when shifts change as an example.

“The EMR now provides us with a ‘sign-out tool’ that allows for documentation of everything we have done for a patient while we were on duty, as well as concerns that we have as we leave our shift,” he said. “This ensures that the hospitalists coming in on the next shift can readily pick up on the situation. We are getting better and better at documentation every year.”

Future of hospital medicine

As hospitals are confronted with an ever-changing landscape — hospitals merging into larger systems, shifts in insurance providers, sicker patients, etc. — the practice of hospital medicine will continue to evolve to meet new challenges.

Lacayo feels that the field will continue to attract medical students, especially for its schedule.

“A lot of new doctors coming out of residency like the idea of working blocks of days with blocks of days off,” he said. “The downside is that you work 50% of your weekends. But having a predictable schedule is attractive to people just coming out of training.”

Lacayo adds another goal for hospital medicine is to keep the number of patients within a specific target.

“There is more turnover in hospitals where hospitalists have to see more patients. When you see fewer patients, you’re able to provide better quality of care,” he said. “Also, I think we will continue to look for alternatives that will allow physicians to care for patients outside of the hospital, rather than admit them.”