Checking in on the Nation's Largest Academic Hospital Medicine Program

Alan L. Wang, MD, Chief Medical Officer at Emory Johns Creek Hospital, Director of Hospital Medicine at Emory University School of Medicine, and Daniel Owens, MBA, Director of Administrative Operations, Division of General Internal Medicine, share their insights into the unique characteristics of academic hospital medicine, the importance of healthcare information technology in providing quality care, and the promising future of Emory Hospital Medicine and the field of hospital medicine.

What makes academic hospital medicine programs unique?

Academic programs afford people the unique opportunity to practice hospital medicine at an academic level so that they are able to blend the mission of academic centers, which include teaching and research, along with patient care. We’re actually a little bit unique at Emory with our system in that we’re at eight different facilities; four of them are very academic, one or two of them are more of a hybrid, and the rest of them are purely community. So we’re able to blend our focus across the board. We have a quality improvement research area, and we have a couple of physicians with us who serve as associate residency directors for the department of medicine for the internal medicine residency program. They are involved in education at the different sites with the residents.

Another unique aspect of our program is our faculty development program. Currently, we have over 80 physicians in our program, and this year we’ll have almost a third of them going into our faculty development that covers four different areas: administration, quality improvement, research, and teaching medical education. We’ve invested in our faculty to develop their clinical tracks to match their areas of interest, so that each hospitalist, as their career develops, can go into their particular niches. We’re very happy to do it and want to reinvest because it helps with their development along with their job satisfaction, which helps to secure our program in the academic ranks.

Owens:

Being in an academic environment, we have to be more on the “cutting edge” with what’s going on, and we’re in a unique position in that we can take that knowledge and transfer it to the community side. We typically get physicians calling us to talk about best practices, and we can take what we’ve learned and help other programs. A lot of that has to do with our quality improvement research. We’re currently doing a pilot program in which we stream data real time onto the wards and floors so that we can catch things proactively, instead of reactively. It allows us to work on intervention on the front end, and know, for example, that a certain patient hasn’t had a beta-blocker or prophylaxis or something like that, and we can make sure they’re being treated with evidence-based medicine.

Have you met with resistance when implementing new technologies?

Owens:

I think change is always difficult in any setting, but I think the healthcare atmosphere now, paralleled by our economy, makes quality paramount. Today, people on the streets can get ratings and indexes of how hospitals are doing, so in everybody’s mind, technology is becoming very important. Plus, evidence-based medicine is also the right thing to practice for the patient. Although change is difficult, I also think everybody on the frontlines understands where medicine and finances are going. Physicians and hospital staff know that this is the direction we must go, so I think that makes it easier. We’re in the age of technology now, and I think that really is going to be a huge step in how quality improvement is overseen.

Wang:

I think that everybody embraces technology and knows that’s the way we need to go. It’s just prioritizing all of the requests, having the manpower to implement those things, and linking it up to electronic medical records as much as possible so that we can harvest the data.

Has your program switched completely over to EMRs?

Owens:

We’re in a hybrid phase right now, with a little bit of paper and a lot of technology. Our academic sites are mostly there, and our community sites are still awaiting word on how the EMRs are going.

What were the biggest challenges you faced when implementing the EMRs?

Owens:

The learning curve and finding the time to get all of our physicians trained without impacting clinical coverage. We’re about to implement a CPOE system at the academic sites this month. We’ve asked our hospitalists to participate heavily in this, because they are on the frontline. If they can give real-time feedback on the functionality of the system, then modifications can be made to it before the go-live date. Also, they can then get the other physicians to buy into the system a little more quickly, because the hospitalists will have already adopted it.

What unique challenges do you face as an academic institution?

Owens:

One of the things that we constantly wrestle with is balancing the three missions of quality patient care, teaching, and research. I think that can’t be said enough, especially with our system that has academic sites, hybrids, and purely community hospitals that we staff .

Wang:

Another really huge part is balancing the quality improvement piece of the program. People are used to seeing research in a science-based methodology, but with hospital medicine, it’s a little bit different. It’s more about clinical outcomes and clinical research rather than bench science. But hospitalists are poised, because we’re right at the center of it all, and we’re really looking at how to improve patient care by using different tools that can be developed. It’s kind of a way to bridge informatics and technology, so it’s sometimes a little difficult to get even academic folks to really understand the kind of research that we’re doing. But at the same time, it’s very important to continue doing what we’re doing.

More than being people who do a lot of the teaching, hospitalists have to be able to work with the outpatient internal medicine doctors and the specialists. We have to be able to coexist and almost function as quarterbacks. Hospitalists have to serve as the main folks that keep everything together.

Why do you think more physicians are choosing careers in hospital medicine?

Wang:

Hospital medicine in some ways can be considered an alternative to outpatient primary care, a field many physicians are turning away from. There’s more stability in going into hospital medicine. Another thing I think people like is the flexibility in the schedule; if you work for seven days straight for 12-hour shifts, then you have the next seven days off. This is appealing especially to husbands and wives that may both work and can arrange their schedule so that there is always someone with the children. Sometimes, a lot of the attraction to a job can be the time spent away from work.

What does the future have in store for hospital medicine?

Wang:

Hospitalists often co-manage with subspecialty groups, such as neurologists or orthopedics. We are starting to see hospitalists specializing in a subset of patient care. Another thing we’ve seen is that hospitalists are starting to sit on a lot of committees and are growing into some elite positions. This makes sense considering that they have to work with all physician groups, almost functioning as gatekeepers. They are poised to be good communicators. Now we are seeing them moving toward high-level administrative roles, and these really impact their work quality with patients. Hospital medicine is a growing field. We have more than 20,000 hospitalists from the data we’ve seen recently, so that means hospital medicine is about to catch the number of cardiologists in the United States. In 1999, when I went to my first hospital medicine conference, there were probably less than a hundred people. Hospitalists are still so new, especially on the academic front, that organizationally, we’re still trying to see how hospital medicine fits into the big scheme. In some places, it’s a department. At some, it’s a division. We are still trying to see how it translates into the teaching infrastructure and the interactions with the other staff . Organizationally, it’s yet to be determined how hospital medicine fits into an academic center—there are different models out there. The field is still constantly growing outward. That is something we will need to stay cognizant of: Where do you draw the boundaries of where hospitalists should take the lead, and where are hospitalists not the best solution?