Wachter: Why Home Hospitals Are Not a Threat

Marcia Frellick

April 18, 2018

ORLANDO — Evidence that home-hospital models lower the cost of care and raise patient satisfaction is strong, but the model has not grown as much as expected in the 20 years since the concept was first promoted, according to Robert Wachter, MD, chief of the division of hospital medicine at the University of California, San Francisco.

"The bottom line is that this must be harder than it sounds," said Wachter during the closing session here at the Society of Hospital Medicine 2018 Annual Meeting.

"We have to be in favor of this because it's good for patients. I hope it grows and I hope we can work it out, but I don't think it's going to be an existential threat to hospitalists," he told the audience.

The growth has been slow largely because the payment system does not create incentives to keep people at home, Wachter explained; however, factors other than cost might be at play.

In 1994, the government in Victoria, Australia, created huge incentives when it began reimbursing home-hospital care at the same rate as traditional, more expensive hospital care. However, an analysis conducted in 2009 showed that hospital-at-home admissions made up only 5% of hospital days (Med J Aust. 2010;193:598-601).

And hospital-at-home programs operating out of the Mount Sinai Health System in New York City, the Presbyterian Health System in Albuquerque, New Mexico, and Kaiser Permanente only cover a small percentage of patients, Wachter reported.

In a 2016 report, Karrie Decker, administrator of home and transition services at Presbyterian Hospital, was quoted as saying that "metropolitan areas of 5 million or more people might provide enough economy of scale to support a full-time team treating at least five or six patients a day."

We've made our hospitals hotels. People get food whenever they need it and someone waits on them.

Doug Rookstool, MD, from the Franciscan Physician Network in Lafayette, Indiana, is skeptical that home hospitals will work well in the United States. They might work better in cultures in which families are more accustomed to taking care of ill relatives at home, he explained. And he is not convinced that patients always prefer home over hospital.

"We've made our hospitals hotels," said Rookstool. "People get food whenever they need it and someone waits on them."

The stakes will get higher as specialties jockey for position, said Wachter. But whatever environment emerges for hospitalists, they will be asked to do more.

"The hospitalist field is safe," he said. However, "our financial model is tenuous, meaning that it depends largely on hospitals giving us some support. We have to continuously demonstrate that we are creating value for the organization."

Other changes are happening quickly. In 3 to 5 years, devices like Amazon's Alexa likely will join physicians in the exam room to perform voice-enabled chart reviews. Companies are already working on devices that can capture the physician's directions, transcribe them, and check the appropriate boxes, said Wachter.

Artificial Intelligence in the Hospital

The technology could then use electronic health record data — from the patient's chart and the charts of other patients — to suggest a particular diagnosis. With this kind of technology on the horizon, the future of medical scribes is not promising.

"Scribes are a transitional and very expensive solution," Wachter said. "Ultimately, I think this function gets replaced by artificial intelligence."

There are some things that computers are very good at and some things that humans are very good at. Only through the thoughtful integration of these two can we hope to drive forward innovation in this field.

Care traffic controllers — who mine and synthesize data, analyze trends related to hospital patients from a command center, and notify physicians when patients fall outside predicted norms — are a good example of how physicians can work with technologists to develop artificial intelligence tools that improve patient care, said Anthony Lin, a third-year medical student at the Duke Institute for Health Innovation in Durham, North Carolina. In a previous session at the meeting, Lin presented data on an artificial intelligence project to predict sepsis early, as reported by Medscape Medical News.

"AI isn't meant to replace clinicians," Lin said, "but to augment the clinical workflow to improve delivery of care. There are some things that computers are very good at and some things that humans are very good at. Only through the thoughtful integration of these two can we hope to drive forward innovation in this field."

In fact, the system only works when human and machine functions are aligned, said Rookstool.

For example, if myocardial infarction is listed as an active problem in a patient's chart but not manually removed once the issue has resolved, the electronic health record will continue to generate an alert that this patient did not receive aspirin, even if the infarction was several hospitalizations ago, he told Medscape Medical News.

Wachter is the author of the book Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. Lin and Rookstool have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2018 Annual Meeting. Presented April 11, 2018.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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