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Predicting the future at Hospital Medicine 2007

Robert M. Wachter, FACP, describes hospital medicine in 2017

By Stacey Butterfield

If anyone could predict the future of hospital medicine, it would be Robert M. Wachter, FACP. In 1996, Dr. Wachter coined the term "hospitalist" in an article in the New England Journal of Medicine. Since then, he's led the movement both nationally and at the University of California, San Francisco, where he is chief of medical service and the division of hospital medicine.

By the year 2017 (when he plans to be retired on a beach in Boca Raton), hospitalists will be busy with more patients, more diseases and more technology, Dr. Wachter predicted during the Society of Hospital Medicine's annual meeting in Grapevine, Texas, in May. The heavier workload will require an ever-growing number of hospitalists, he said, pushing their numbers from the current 20,000 to 50,000 in 10 years, with growth increasingly driven by co-management of surgical patients.

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Changes in working conditions, income

More and more surgeons are turning management of their patients' comorbidities over to hospitalists, and other specialists are likely to do the same, Dr. Wachter said.

"Hospitalists will essentially be touching every patient who is sick enough to benefit from their care."

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Hospital Medicine 2007 was held May 23–25 in Grapevine, Texas. Photo by Bill Strouse

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Cuts in resident work hours, of which Dr. Wachter expects to see more, will also increase the need for hospitalists. Allied health professionals may pick up some of the residents' work, but because physicians bill at higher rates, work unpaid overtime and aren't unionized, Dr. Wachter predicted greater growth in the ranks of hospitalists.

As for hospitalist income, Dr. Wachter said salaries will increase until supply meets demand, with funding continuing to depend on two streams: professional fee revenues and support from hospitals.

Future reimbursements also will be based on quality measures, which will evolve to record patient outcomes rather than treatment processes, Dr. Wachter predicted.

"Ultimately, we actually don't care whether the patient got a beta blocker or a blood culture. We care about how patients do," he said.

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Changes in outcome measurement, technology

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Robert M. Wachter, FACP, addresses attendees at a Hospital Medicine 2007 session. Photo courtesy of the Society of Hospital Medicine.

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Comparisons of observed versus expected outcomes will be the crucial performance measurement in the not-too-distant future. At that point, when case-mix adjustors can compare a patient's recovery or survival with that of other patients in the same condition around the country, pay-for-performance programs will gather more steam, said Dr. Wachter.

These more in-depth performance measurements will be made possible by electronic medical records (EMRs), which by 2017 will be universal, Dr. Wachter said.

"It will be very difficult to say 'I don't have an EMR' and not have people look at you cockeyed," he said.

EMRs of the future will do more than facilitate information transfer and eliminate confusion over handwriting, however.

"The big transformative force here is that all the data are owned by the patients in the patient-owned universal record," Dr. Wachter said.

Patients, rather than health care providers, will control their own EMRs, using Internet software likely developed by one of the mainstream computer giants, such as Google or Microsoft. The record will calculate expected outcomes automatically and collect patients' vital signs through sensors.

"The question you need to ask in 2017 might not be 'Does the patient need a CAT scan?' The hospitalized patient may get a scan with breakfast every morning and we just decide which slices to look at," Dr. Wachter said.

In the future, data will be coming in from every direction, from watches that measure blood pressure to beds that record heart and respiratory rates.

"We [hospitalists] will be charged with making sense of all this," said Dr. Wachter.

Other new technology will assist hospitalists in finding help to sort through the data. Like many other hospitals, UCSF Medical Center recently added plasma screens in patients' rooms.

"Right now, it's there so they can watch CNN," said Dr. Wachter. In 2017, though, hospitalists may use the screen to meet with a patient's daughter in another state and a specialist somewhere else in the world. The hospitalist could run a search for a nephrologist and get a list of consultants who are currently online, along with their cost and quality scores. And internists, specialists, patients and family members might be able to meet in real time to discuss test results and treatment options.

"To me, that sounds spectacular," Dr. Wachter said. It might even be enough to lure a retired hospitalist back from the beaches of Florida.

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