American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tuesday, January 21, 2014

5 elusive problems for hospitals everywhere

As health care reform sets in, hospitals are gearing up for many challenges. While some of these are new to the health care industry, several are against the backdrop of very old problems that have plagued us for decades. Speaking as a doctor who has worked in a number of different hospitals up and down the East Coast, I would like to identify 5 of these that I believe are fairly universal:

1. Medication reconciliation

This is being certain about what the patient’s correct medications should be, and is both a problem on admission and upon discharge. Not knowing the patient’s correct medications when they are first admitted to hospital can naturally start off a chain of events that leads to adverse medical events. The same applies to when a patient is discharged, when any medications changes (including new ones) must be made clear. How does the confusion arise? Well, for a number of reasons including the fact that a patient who takes several pills may not always remember the names and exact dosages. There’s often nowhere for the doctor to go, especially outside of regular business hours, to obtain an accurate list. What hospitals need is a simple “no ifs, ands or buts” medication list. Studies are increasingly showing that pharmacists are the ones who are best placed to do this. Having a pharmacist stationed in the ED is a great idea, to hand every doctor who is admitting the patient a complete and accurate list. The same should happen on discharge, and can be targeted to high-risk patients. Think this is expensive for hospitals? Imagine the money (and lives) saved by reducing medical errors.

2. Dealing with patients’ most basic complaints

Nowadays, hospitals and health care organizations are using too many gimmicks when it comes to improving patient satisfaction and enhancing the patient experience. These include things such as flashy surveys, customer service agents, and computer Apps. Forget these. Why not just listen to your patients’ most basic complaints? Two of these would be getting a good nights’ sleep and tastier food! These are by far the 2 biggest complaints that I hear each and every day. Hospitals everywhere are failing to grasp the fact that what patients want is really quite simple. The list would also include more time with their doctors. It’s not rocket science. Listen, learn and create the right hospital environment.

3. Poor Information Technology systems

Unfortunately, most of the current IT systems are slow, cumbersome and inefficient. They make life more difficult for doctors and nurses, and take precious time away from patients. This applies both to Computerized Physician Order Entry (CPOE) and medical documentation. I’ve seen many people in health care informatics very enthusiastic about the new technology that’s being introduced into hospitals. Often many of them are the first to admit that the platforms are terrible. This would be akin to getting excited about delivering an awesome new traffic solution for a big city, knowing full well that the roads are completely broken! Hospitals shouldn’t make the mistake of planning a multi-million dollar investment in the wrong technology. The solutions of the future will be well thought-out and also utilize smart devices instead of PCs with keyboards and mouses.

4. Standardizing rounding

The way that hospital doctors round on their patients up and down the country is completely haphazard at the moment. One patient may get seen at 7 am and another at 3 pm. Often there’s no rhyme or reason behind the timing; it’s just about where the patient happens to be located in the hospital. Communication between nurses and doctors is also often sadly lacking. It’s not untypical for there to be no communication at all between the doctor and nurse either before or after seeing the patient. That’s unacceptable. A way to improve on this is to institute a full Multidisciplinary Rounding model. In this system, rounding is standardized to include all members of the care team, ideally also going into the patient’s room together.

5. Discharge

The discharge process is fraught with potential problems by its’ very nature. It needs to be as thorough and flawless as possible. Medications need to be checked and double checked, and all follow-up instructions should be made crystal clear. There are many ways to accomplish this, from a thorough patient handout to a dedicated discharge coordinator. Either way, the patient and family need to know the exact diagnosis and plan. This goes a long way to helping reduce readmissions and keeping the patient on a healthier path for the future. Having a good amount of time with the doctor sitting down with the patient and family immediately prior to discharge is also something to strive for.

If we could just solve the above 5 problems in our health care system, we will be taking a huge leap forward. The answers aren’t necessarily complicated or particularly expensive. They will require focus and collaboration across a range of professionals involved in hospital processes. When we address them in a standardized and evidence-based way, it will not only save the system money, but also make medical care safer and a better all-round experience. Let’s get to work.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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