• E-mail
• Print
• PDF

Technology and hospitalists: A complex relationship

Hospitalist Management Advisor, September 1, 2008

In the continuously changing field of hospital medicine, with a work pool of relatively young hospitalists, common wisdom would indicate that practitioners are always on the lookout for new and innovative technologies. Although some hospitalists are incorporating advanced medical and clinical technologies into the work environment, the technology change isn’t as fast as some might expect. Rather, it is communication technology that hospitalists seem most prone to incorporate. In addition, none of the technology changes are necessarily resulting in more hospitalist hires, according to a May study.

Studying the background

The study, Does Advanced Medical Technology Encourage Hospitalist Use and Their Direct Employment by Hospitals? considered the relationship between hospital rates of purchasing innovative clinical technology and hospitalist employment rates.

“One hypothesis in the field is that hospitalists are better at managing technology, better gatekeepers, and don’t prescribe as many unnecessary tests,” says Guy David, PhD, a health economist in The Wharton School of the University of Pennsylvania in Philadelphia and lead author of the study. David’s study showed this not to be the case, in large part because hospitalists aren’t typically the ones using highly advanced medical equipment.

Researchers studied 3,413 community, nonfederal hospitals that bought and used medical technologies: intensity-modulated radiation therapy, gamma knife, and multislice CT. Researchers found that although there is a good chance that hospitals with this kind of clinical equipment have hospitalist programs, the two aren’t necessarily linked.

The study found that hospitals that had this newer clinical equipment were more likely to use hospitalists. Surprisingly, however, there was no causal correlation that it was hospitalists who drove the technology acquisitions or that they, in particular, used it more efficiently. Hospitals that purchased this equipment were not more likely to add a hospitalist group or increase its hospitalist staff.

The study did have some limitations, David said. It looked only at three types of equipment and gave no reasons the hospitals purchased the technology, which made it impossible to tell why this correlation between technology and hospitalists existed. He says there are several reasons why that was the case: Hospitals with this medical equipment often are larger facilities, have more money, and are more innovative, making it more likely they can afford and bring on hospitalist groups. Without further investigation, the study only showed that if a hospital is considering purchasing new technologically advanced equipment, its reason shouldn’t be because hospitalists are more likely to ensure its proper use. The study showed hospitalists have no effect on how the equipment is used.

Technology at use: Communication vs. clinical

One reason David’s study might not have found a causal relationship between advanced medical technology and the use of hospitalists is that it’s unlikely hospitalists would use much of the new technological medical equipment, says Russ Cucina, MD, MS, assistant professor of hospital medicine and associate medical director of information technology at the University of California, San Francisco.

But that doesn’t mean hospitalists aren’t seeing their worlds change because of new technology, Cucina says. It’s just that the technology is more communication- and record-based than it is clinical.

“Most of the changes have been in information technology,” Cucina says. “Electronic medical records [EMR], bar-coded medication administration, electronic guidelines adherence, and computerized physician order entry [CPOE] are the new wave of technology that hospitalists are leading the way on.”

EMRs make the push

With the current presidential administration attempting to make EMRs a standard practice across the country, hospitals continue to share the information using different media types and more frequently than ever before, Cucina says.

“All the other information technology presupposes that a physician is electronically documenting,” Cucina says. Physicians can order medications electronically, which then allows nurses to administer to patients using a bar-code system that verifies the correct drug and dosage given to the patient. EMRs also make electronic guideline adherence possible, ensuring that a physician remembers a simple regulation such as always giving a myocardial infarction patient a beta-blocker or an aspirin on discharge.

“The new technology is helping hospitals in a lot of ways, but the pace of development is quite a bit slower than in other software industries,” Cucina says. “It’s a much more conservative and slowly paced industry for technology, partly because the tolerance for error is literally zero. If you put medicine into a person and it’s wrong, there’s no taking it back.”

Clinical work flow is also tough to alter, Cucina adds. Bridging the gap to performing clinical work and supporting that work with software can be challenging.

Hospitalists are bridging the gap

Those physicians most likely to bring newer technology into the hospital are hospitalists, says Peter Lindenauer, MSc, medical director of clinical and quality informatics and associate professor of medicine at Bay State Medical Center in Springfield, MA.

Whether it’s because of the young age of hospitalists or the time spent in the hospital, “hospitalists almost always have the highest rates of electronic orders,” he says.

CPOEs are the hottest area right now and the one in which hospitalists are especially at the forefront, says Lindenauer. “[CPOEs have] been around for years, but now with the Institute of Medicine and [the Leapfrog Group for Patient Safety] touting its benefits, people are really getting on board,” he says.

Many physicians have been slow to adopt CPOE, despite its benefit of reducing medication errors, because it’s difficult to implement, especially for medical staff members who do not use it all the time, Lindenauer says. Primary care physicians (PCP) and subspecialists are accustomed to paper orders. If staff members aren’t regularly using computerized orders, they may be more apt to make mistakes or spend too much time on orders, he says.

But hospitalists get the proper training and have the time to use CPOE often, which is necessary to make it effective and efficient, Lindenauer adds.

“I think it’s the kind of thing that as hospitals invest in this type of technology, what they observe is that they don’t have problems,” he says.

Becoming hardwired

However, it’s not only software that hospitalists are putting to good use, Cucina says. More programs are starting to use communication technology such as:

• Dual-mode cell phones
• PDAs
• Tablet computers
• Trio or BlackBerry-type phones

The advantage of portable communication devices is that physicians can access EMRs or lab results at all times from the hospital or even from home, Cucina says.

Unlike in nonhospitalist settings, hospitalist information technology costs are necessary to the investment.

“The shared administration gives you the opportunity to show the hospital it has a stake in providing that efficiency,” he says.

There is also starting to be a push toward physicians using dual-mode phones instead of pagers because they can get a signal anywhere, Cucina explains. One area in which hospitalists are proving slow to adapt is the use of laptops and tablet computers—devices that many nurses have become more accustomed to using, he says.

But even that may be starting to change with the Motion Computing C5 tablet. It’s small, has a handle, is durable, and can be sterilized, all which eliminate many of the reasons most physicians still use PCs.

One other technological change that Lindenauer says he has seen recently is an increase in physician text messaging.

“We’ve seen a widespread use of text messaging between providers as way of communication that doesn’t involve numeric pagers that require callbacks,” he says. “As long as you don’t include patient identifiers, it’s a quick, efficient way to get a message across.”

Making the financial case

Budgetary constraints make it difficult for hospitalists to continue taking advantage of the newer technologies that have the potential to make them more efficient and keep them in better contact with records, other physicians, and patients.

“You have to make the case that providing advanced information technology will result in [return on investment (ROI)], shorter lengths of stay, or more revenue per diagnosis,” Cucina says. “Hopefully, you can show that if you can reduce adverse drug events by a little bit, there is a large ROI.”

CPOE systems have been shown to reduce adverse drug events by up to 40%, Cucina adds, which could save the hospital a lot of money in the long run. However, he says, it’s more difficult to show that they improve clinician efficiency, especially communication technology such as PDAs and more advanced phones.

Because most hospitalist programs are already being subsidized by the hospital, it makes it even more difficult to justify some of the high-priced software systems. But if you can show an ROI through costs or better patient care, most hospitals will listen, Cucina says.

• E-mail to a Colleague
• Print