Because it’s still the new kid on the block, hospital medicine is entitled to develop some new terminology and labels.
Probably the best example is the moniker that now defines what we do for a living: hospitalist. Other labels that have followed suit include nocturnist, for those of us who work only at night; procedurelists, for hospitalists who do nothing but procedures; and surgicalists, for general surgeons who work only on-site and take surgeries coming through the ED. Neurohospitalist is another new tag for a type of specialized hospitalist.
Please allow me to suggest another one: the admitologist!
We all constantly analyze how we work and look for ways to improve efficiency, cut out waste and streamline care.
We also keep holding on to an ideal of being able to admit, round on and discharge the same patient–what I call the "artisan" model of hospital medicine. When we both admit and follow a patient, we get a sense of ownership for the process of providing care and the ability to get to know that patient. The artisan model is held out as the epitome of "continuity of care."
But let’s step back a minute. The whole concept of hospital medicine challenges the model of continuity of care. As hospitalists, we have traded in continuity for other gains: allowing primary care physicians to concentrate on their outpatient practice; giving specialists time to focus on the procedures that they do best; and ensuring around-the-clock availability of (different) physicians for patients and families, as well as for nursing staff. Given the shift-based nature of hospital medicine, this type of fragmented care places a premium on communication skills and work processes. Our biggest challenge is how to pass patient information from provider to provider across day and night shifts, without degradation, mutation or a "voltage drop" loss.
Take a look at best practices from outside of health care. I want to focus on two of them: the assembly line model of production–which I know sounds horrible in the context of health care–and parallel processing.
Assembly line techniques revolutionized car manufacturing when Henry Ford implemented them to build the indomitable Model T. Similarly, parallel processing is a term of art in computing. It refers to a processing model in which data are broken down into their logical components or packets and then processed side by side by different computers in a network. The advantage of parallel processing with a network of computers–instead of having data processed serially by only one computer–is that it takes much less time. (Here’s a look at how hospitals are incorporating other lessons from other industries.)
When I look at hospitalists’ daily workflow, here’s where I see the biggest disruptions: unplanned admissions( and virtually all admits to a hospitalist team are unplanned, either from patients showing up in the ED or being referred for their primary physician’s office); unplanned family conferences; and sudden deterioration in a patient’s status.
We really can’t control Nos. 2 and 3. But what if we designed workflow so one provider does nothing but admits patients, allowing other physicians to round, coordinate care, and figure out who’s ready for (and how best to structure) discharge?
In busy hospitals, patients often wait hours for admission orders, time they spend deprived of nourishment, analgesics and antiemetics. Having an admitologist could alleviate this problem. Depending upon a hospital’s typical number of admissions, the admitting physician can team up with one or more midlevels to further extend his or her reach and minimize the time spent waiting for orders and charting out the plan of care.
The admitologist can also do triage, reducing that burden on the rounding team. This model incorporates both the assembly line concept and that of parallel processing, allowing admission and rounding to proceed side by side, instead of one after the other by the same physician. The rounding physician is able to stay in the "rounding state of mind," concentrating on treatment plans and discharge orders; the same would be true for the admitologist. Each would be able to better consolidate his or her work.
Would admitologists and rounders switch roles? I think that’s for teams to decide. Some docs might thrive as full-time admitologists, honing their ability to form a differential diagnosis. On the flip side, physicians probably will not liked to pigeon holed further and suffer a loss of skills. Probably, teams that adopt this model–which I hesitate to call "industrial" vs. the "artisan" model of hospital medicine–will rotate physicians at varying degrees of frequency, depending on their needs and the hospital system.
It’s true that such a model automatically introduces another handoff, between the admitologist and the rounder. It’s also true that hospitals with high admission rates as well as an EMR (or, at least, CPOE) would be better positioned to benefit from such an approach. Before putting such a model in place, hospitalists would have to nail down lines of communication and design processes to capture key information. But isn’t the model worth trying?