so that, for example, some radical thinkers in the nineteenth century might embrace “improvement” in the sense of scientific farming, without its connotation of commercial profit

The word “improve” itself, in its original meaning, did not mean just “making better” in a general sense but literally (based on the old French for “into,” en, and “profit,” pros, or its oblique case, preu) doing something for monetary profit, and especially cultivating land for profit. By the seventeenth century, the word “improver” was firmly fixed in the language to refer to someone who rendered land productive and profitable, especially by enclosing or reclaiming waste. Agricultural “improvement” was by then a well established practice, and in the eighteenth century, in the golden age of agrarian capitalism, “improvement,” in word and deed, came truly into its own.

The result was an agrarian sector more productive than any other in history. Landlords and tenants alike became preoccupied with what they called “improvement,” the enhancement of the land’s productivity for profit.

This pattern would be reproduced in the colonies, and indeed in post-Independence America, where the independent small farmers who were supposed to be the backbone of a free republic faced, from the beginning, the stark choice of agrarian capitalism: at best, intense self-exploitation, and at worst, dispossession and displacement by larger, more productive enterprises.

To meet economic rents in a situation where other potential tenants were competing for the same leases, tenants were compelled to produce cost-effectively, on penalty of dispossession.

The effect of the system of property relations was that many agricultural producers (including prosperous “yeomen”) were market-dependent, not just in the sense that they were obliged to sell produce on the market but in the more fundamental sense that their access to land itself, to the means of production, was mediated by the market.

Landlords had a strong incentive, then, to encourage—and, wherever possible, to compel—their tenants to find ways of increasing their output. In this respect, they were fundamentally different from rentier aristocrats who throughout history have depended for their wealth on squeezing surpluses out of peasants by means of simple coercion, enhancing their powers of surplus extraction not by increasing the productivity of the direct producers but rather by improving their own coercive powers—military, judicial, and political.

From an economic point of view, this must be one of the oddest projects in the world.. No net gain in floor space for a billion dollar plus privately funded project. This projects exists in one of the most individual economic circumstances in the world. That the CIty of Sydney was unwilling to bend their ridiculous morning Solar Access Plane into Macquarie Park and allow a new tower on Loftus St, leading to this ridiculous FSR swap and wasteful construction... Madness. City of Sydney is the *definition* of champagne socialists. They are too rich, and have too much control over *our* CBD, for a Sydney of 5 million people, not their 250,000 inner city residents.

In this country, in other words,

Macquarie Tower-18

(water vapor, carbon dioxide, nitrous oxide, and methane,

Scientists think that the things people do that send greenhouse gases into the air are making our planet warmer.

Sunlight enters the Earth's atmosphere, passing through the blanket of greenhouse gases

rise in temperature

When we burn these fossil fuels, the carbon combines with oxygen to make carbon dioxide. This extra carbon dioxide (and other GHGs like methane) traps more and more heat in our atmosphere.

Perhaps, he realized, these viruses don’t actually need to unite their segments in the same host cell. “If theory was saying that this is impossible, maybe the viruses just don’t do it,” he says. “And once we had this stupid idea, testing it was very easy.”

'You can always tell a person by their shopping,' was one of her mother's favourite maxims. She looked into her shopping basket: individual fruit pies, small salad cream, yoghurt, tomatoes, cat food and a chicken quarter.The cashier suddenly said, 'Make it out to J. Sainsbury PLC.' She was addressing a man who had been poised and waiting to write out a cheque for a few moments. His wife was loading what looked like a gross offish fingers into a cardboard box marked "Whiskas". It was called a division of labour.Jean looked again at her basket and began to feel the familiar feeling of regret that visited her from time to time. Hemmed in be­tween family-size cartons of cornflakes and giant packets of wash­ing-powder, her individual yoghurt seemed to say it all. She looked up towards a plastic bookstand which stood beside the till. A slim glossy hardback caught her eye. The words Cooking for One screamed out from the front cover. Think of all the oriental foods you can get into, her friend had said. He was so traditional after all. Nodding in agreement with her thoughts Jean found herself eye to eye with the blonde woman, who gave her a blank, hard look and handed her what looked like a black plastic ruler with the words "Next customer please" printed on it in bold letters. She turned back to her friend. Jean put the ruler down on the conveyor belt.

such as scope, simplicity, fruitfulness, accuracy

Like in evolution, the process does not change toward some fixed goal according to some fixed rules, methods or standards, but rather it changes away from the pressures exerted by anomalies on the reigning theory (Kuhn 1962, 170–173). The process of scientific change is eliminative and permissive rather than instructive.

Japanese

Crucial to understanding the workings of power is an understandingof the nature of power in the fullness of its materiality. To restrict power’sproductivity to the limited domain of the “social,” for example, or tofigure matter as merely an end product rather than an active factor infurther materializations, is to cheat matter out of the fullness of its capacity.

Any local, state or national government, or any political machine, in order to live, must give the people assurance that they can express their will freely and that their votes will be counted. The most powerful machine cannot exist without the support of the people. Political bosses and political machinery can be good, but the minute they cease to express the will of the people, their days are numbered.

the vote of no confidence

Writers who continue to support an outmoded concept of the lone writer dissociated from the various niche communities at their disposal will eventually lose touch with the nanosecond speed at which the movement-chemistry wanders and will find their own work and its individually-isolated movement decelerating into turtle-like oblivion

Soon the Data Superhighway will finally once and for all do away with the high-priced middlemen, and artists will reap the benefits of their own hard-earned labor. The distribution formula will radically change from Author - Agent - Publisher - Printer - Distributor - Retailer - Consumer to a more simplified and direct Author (Sender) - Interactive Participant (Receiver)

We refer to a way of life

supported the aristocracy, from whom she benefited

Most of Astell's discussion of rhetoric is devoted to style,

ou please your selves.

communicating

“In spite of the high cost of rescuing the banks and the rising inequality across society revealed by the recession, the shrinking of the state has continued, led by the vain hope that markets will find a way of bringing a miraculous revival if left to themselves. History has shown that this is the wrong moment for that. Yet the current economic orthodoxy, incapable of explaining the crashes, holds on to an interpretation of how the economy functions that ignores the role of technology and the accumulated learning of the other social sciences. It has taken refuge in increasingly complex mathematical models, as if economics were more closely akin to physics. Worse still, these economists and many of their critics are still waging the ideological battles of the 1960s and 1980s, without realising that we are now in a completely different context—one that has more in common with the 1930s … If the advanced world governments stay on the current austerity path, they will wait forever for the market to do the right thing for growth and social well-being …

Structural adjustment and its results as another source of wealth transfers to US capitalists in the 1980s

he same in all nations, and consequently can e

ing from what

of nonverbal communication.

the delivery or a speech

ಅನಾದಿಯಾಗಿ ಪಶು ಪಾಶ ಮಲ ಮಯಾಕರ್ಮಗಳುಂಟಾದರೆ,ಈ ಜಗವನೊಬ್ಬರೂ ಸೃಷ್ಟಿಮಾಡಿದ ಕರ್ತುವಲ್ಲ.ಎಂದೆಂದೂ ಜಗವಿದ್ದಿತ್ತು ನಿತ್ಯವೆನ್ನು.ಎಂದೆಂದೂ ಜಗವಿದ್ದಿತ್ತೆಂಬೆಯಾದರೆ,ಶಿವನ ಸೃಷ್ಟಿ, ಸ್ಥಿತಿ, ಸಂಹಾರ, ಸ್ಥಿರೋಭಾವ, ಅನುಗ್ರಹವೆಂಬಪಂಚಕೃತ್ಯಗಳು ಹುಸಿಯೆಂದೆನ್ನು.ಶಿವನಿಗೆ ಸೃಷ್ಟಿ ಸ್ಥಿತಿ ಸಂಹಾರಾರ್ಥವುಂಟಾದರೆ,ಈ ಜಗತ್ತೆಲ್ಲವೂ ಶಿವನ ನೆನಹು ಮಾತ್ರದಿಂದ ಹುಟ್ಟಿತ್ತಲ್ಲದೆ,ಎಂದೆಂದೂ ಉಂಟೆಂಬುದು ಶೈವ ಪಶುಮತವಲ್ಲದೆ,ವೀರಶೈವರ ಮತವಲ್ಲ.ವೀರಶೈವರ ಮತವೆಂತೆಂದಡೆ:ಘನ ಗಂಬ್ಥೀರ ವಾರಿದ್ಥಿಯೊಳಗೆ ಫೇನತರಂಗಬುದ್ಬುದ ಶೀಕರಾದಿಗಳು ತೋರಿದಡೆ,ಆ ಸಾಗರ ಹೊರಗಾಗಿ ತೋರಬಲ್ಲವೇ?ಆ ಪರಶಿವಸಾಗರದಲ್ಲಿ ತೃಣಾದಿ ಬ್ರಹ್ಮಾಂತವಾದ ದೇಹಿಗಳುಉತ್ಪತ್ತಿಯಾಗಿ ಮತ್ತಲ್ಲಿಯೇ ಅಡಗುತ್ತಿಪ್ಪರು ನೋಡಾ.ಇದು ಕಾರಣ, ಲಿಂಗನಿರ್ಮಿತದಿಂದ ಜಗತ್ತಾಯಿತೆಂದೆ ಕಾಣಾ,ಮಹಾಲಿಂಗಗುರು ಶಿವಸಿದ್ಧೇಶ್ವರ ಪ್ರಭುವೇ.

ಆವ ಜಾತಿಯಲ್ಲಿ ಹುಟ್ಟಿದವನಾದಡಾಗಲಿ,ಶ್ರೀಮಹಾದೇವನ ನೆನೆವಾತನದ್ಥಿಕ ನೋಡಾ.ಆತನಿಂದದ್ಥಿಕ ಕಂಗಳು ತುಂಬಿ ನೋಡುವಾತ.ಆತನಿಂದದ್ಥಿಕ ಕೈಮುಟ್ಟಿ ಪೂಜಿಸುವಾತ.ಅದೆಂತೆಂದಡೆ, ಶಿವಧರ್ಮೇ-``ಲಿಂಗಸ್ಯ ದರ್ಶನಂ ಪುಣ್ಯಂ ದರ್ಶನಾತ್ ಸ್ಪರ್ಶನಂ ಶುಭಂ |ಶಿವಲಿಂಗಂ ಮಹಾಪುಣ್ಯಂ ಸರ್ವದೇವ ನಮಸ್ಕøತಂ |ಯಃ ಸ್ಪøಶೇದಪಿ ಪಾಣಿಭ್ಯಾಂ ನ ಸ ಪಾಪೈಃ ಪರಿಲಿಪ್ಯತೇ ||''ಎಂದುದಾಗಿ,ಅಂತಪ್ಪ ಶಿವಲಿಂಗವನು ಹೆರೆಹಿಂಗದೆ ಅಂಗದ ಮೇಲೆನಿರಂತರ ಧರಿಸಿಕೊಂಡಿಪ್ಪಾತನೆ ಎಲ್ಲರಿಂದದ್ಥಿಕ ನೋಡಾಅಖಂಡೇಶ್ವರಾ.

not with Dollars”

t must be allowed, that there are certain qualities in objects, which arc fitted by nature to produce those particular feelings.

By this means, his sentiments are perverted; nor have the same beauties and blemishes the same influence upon him, as if he had imposed a proper violence on his imagination, and had for­gotten himself for a moment. So far his taste evi­dently departs from the true standard; and of con­sequence loses all credit and authority

pardons twenty absurdities and defects for one elevated or pathetic stroke.

each mind perceives a differentbeauty.

Speech and thought arc inseparable, in Vico'., view: They evolve together.

\·e11.m.\· c·o1111111111i

all five clas�ical canons (invention, arrangement, style, memory. and deli\'· cry),

I Know not how to Please All, t

there being a Large Market-place, you may stand or sit with Ease and hear the Orations that are there Spoken

He that has complex ideas, without particular names for them, would be in no better case than a bookseller, who had in his warehouse volumes that lay there unbound, and without titles, which he could therefore make known to others only by showing the loose sheets, and communicate them only by tale.

Without this, men fill one another's heads with noise and sounds;

Vico, Sheridan, and Campbell, as well as a number of philosophers, pursued Locke's suggestive but incomplete account of the relation-ship of language and knowledge, though never far enough to link rhetoric explicitly with the process of creating "true" knowledge. T

three days

A Patient's Bill of Rights

preexistingthings

we are a part of that nature we seek to understan

summary,

My argument is that today the critical posthumanities are emergingas post-disciplinary discursive fronts not only around the edges ofthe classical disciplines but also as o

no, you know, that is kind of the holy grail for every retail trader.

no, and I was talking to her at the meetup and find it very useful to see all my accounts on these three exchanges on one screen. I don't want to have to log in to each one separately and keep track of how much coins I have on each. I would rather see this on one screen every morning. I pull up the screen easy to see. I don't necessarily need to trade from that screen, but I can just an idea of what holdings I have because I'm constantly rebalancing.

o I can't be pulling up my internet browser on my phone and loading the desktop version and some of these charts or some of these apps I need the mobile.

An example would be three commas, my main use case for it has been the market orders

we are a part of that nature we seek to understan

Beware lest ye contend with anyone, nay, strive to make him aware of the truth with kindly manner and most convincing exhortation. If your hearer respond, he will have responded to his own behoof, and if not, turn ye away from him, and set your faces towards God’s sacred Court, the seat of resplendent holiness.

The weakest first factor accounted for 18.3% of variance

We must have an agency of the federal government to pMtett it.

o one, or almost no one, fads to beheve 1n climate chan~Je out of sincere ignorance. Ttiey •choose-to d1sbeheve either for material gain or 1ust to be dicks.

To doubt Blum was to doubt the traditional edu-cational system and therefore the entire society. Nobody wanted to do it.

ater developments build on this.

waxedand waned

There is a profound disorientation.

It is the story that hid my humanity from me

f to do thatis human, if that's what it tak§, tnen I am a human being after all. 'Fully, freely, gladly, for tneficst time.

The society, the civilization they were talking about, these theoreti-cians, was evidently theirs; they owned it, they liked it; they were human, fully human, bashing, sticking, thrusting, killing. Wanting to be human too, I sought for evidence that I was; but if that's what it took, to make a weapon and kill with it, then evidently I was either extremely defective as a human being, or not human at all. That's right, they said. What you are is a woman. Possibly not human at all, certainly defective. Now be quiet while we go on telling the Story of the Ascent of Man the Hero

UTILITARIANISM

Ammgeme/11.

Access to gender-responsive substance use disorder treatment services, especially for pregnant women

Overall, recovery studies suggest that subcategories of the recovery process exist. However, different units of analysis (e.g., individual versus group) or different types of groups (e.g., based on ethnicity or social class) may experience the phases of recovery at differing rates. Thus, patterns, phrases or cycles of recovery are not linear.

my proceedings in my days

Our under-standing of the gap is driven by technological exploration through artifact cre-ation and deployment, but HCI and CSCW systems need to have at their corea fundamental understanding of how people really work and live in groups, or-ganizations, communities, and other forms of collective life. Otherwise, wewill produce unusable systems, badly mechanizing and distorting collabora-tion and other social activity.

The gap is also CSCW’s unique contribution. CSCW exists intellectually atthe boundary and interaction of technology and social settings. Its unique intel-lectual importance is at the confluence of technology and the social, and its

Nonetheless, several guiding questions are required based on thesocial–technical gap and its role in any CSCW science of the artificial:• When can a computational system successfully ignore the need fornuance and context?• When can a computational system augment human activity withcomputer technologies suitably to make up for the loss in nuance andcontext, as argued in the approximation section earlier?• Can these benefits be systematized so that we know when we are add-ing benefit rather than creating loss?• What types of future research will solve some of the gaps betweentechnical capabilities and what people expect in their full range of so-cial and collaborative activities?

The final first-order approximation is the creation of technical architecturesthat do not invoke the social–technical gap; these architectures neither requireaction nor delegate it. Instead, these architectures provide supportive oraugmentative facilities, such as advice, to users.

Another approximation incorporates new computational mechanisms tosubstitute adequately for social mechanisms or to provide for new social issues(Hollan & Stornetta, 1992).

First-order approximations, to adopt a metaphor from fluid dynamics, aretractable solutions that partially solve specific problems with knowntrade-offs.

Similarly, an educational perspective would argue that programmers andusers should understand the fundamental nature of the social requirements.

CSCW’s science, however, must centralize the necessary gap between whatwe would prefer to construct and what we can construct. To do this as a practi-cal program of action requires several steps—palliatives to ameliorate the cur-rent social conditions, first-order approximations to explore the design space,and fundamental lines of inquiry to create the science. These steps should de-velop into a new science of the artificial. In any case, the steps are necessary tomove forward intellectually within CSCW, given the nature of the social–tech-nical gap.

Ideological initiatives include those that prioritize the needs of the peopleusing the systems.

Simon’s (1969/1981) book does not address the inevitable gaps betweenthe desired outcome and the means of producing that outcome for anylarge-scale design process, but CSCW researchers see these gaps as unavoid-able. The social–technical gap should not have been ignored by Simon.Yet, CSCW is exactly the type of science Simon envisioned, and CSCW couldserve as a reconstruction and renewal of Simon’s viewpoint, suitably revised. Asmuch as was AI, CSCW is inherently a science of the artificial,

At a simple level,CSCW’s intellectual context is framed by social constructionism andethnomethodology (e.g., Berger & Luckmann, 1966; Garfinkel, 1967), systemstheories (e.g., Hutchins, 1995a), and many large-scale system experiences (e.g.,American urban renewal, nuclear power, and Vietnam). All of these pointed tothe complexities underlying any social activity, even those felt to be straightfor-ward.

Yet,The Sciences of the Artificialbecame an an-them call for artificial intelligence and computer science. In the book he ar-gued for a path between the idea for a new science (such as economics orartificial intelligence) and the construction of that new science (perhaps withsome backtracking in the creation process). This argument was both charac-teristically logical and psychologically appealing for the time.

The HCI and CSCW research communitiesneed to ask what one might do to ameliorate the effects of the gap and to fur-ther understand the gap. I believe an answer—and a future HCI challenge—is toreconceptualize CSCW as a science of the artificial. This echoes Simon (1981)but properly updates his work for CSCW’s time and intellectual task.2

because people of-ten lack shared histories and meanings (especially when they are indiffering groups or organizations), information must berecontextualized to reuse experience or knowledge. Systems often as-sume a shared understanding of information.

Whereas I say, that things as objects of our senses existing outside us are given, but we know nothing of what they may be in themselves, knowing only their appearances, i. e., the representations which they cause in us by affecting our senses. Consequently I grant by all means that there are bodies without us, that is, things which, though quite unknown to us as to what they are in themselves, we yet know by the representations which their influence on our sensibility procures us, and which we call bodies, a term signifying merely the appearance of the thing which is unknown to us, but not therefore less actual. Can this be termed idealism? It is the very contrary.

that experience,

The specter of upcoming departure influenced behavior in a way that removed one from reality — academics in Lyon mattered less at home, new friends would return to their countries of origin and communication would lapse, and why invest for comfort when somewhere so briefly?

Not in Austin, but near, and often visiting. Twenty miles North. Sometimes, further

technical difficulties

Canada is the first case of the expansion of hospital medicine beyond the United States, and as of 2008, Canada had more than 100 hospital medicine programs.7 Currently, the estimated number of hospitalists in Canada has increased to ~3,000 (Colleen Savage, Administrator, Canadian SHM, personal communication, December 6, 2017). Yousef and Maslowski describe several drivers for the development of the hospitalist model, which are related to physicians, patients, and systems. Work–life balance and the desire for non-hospital work among primary care providers (PCPs) were leading physician factors. Two major patient-related factors were the increasing age and complexity of patients and the increasing number of “unattached” patients. Unattached patients are those who either do not have a PCP or their PCP does not have admitting hospital privileges. System drivers included PCP shortages, reduction in resident duty hours, higher need for health system efficiency, and cost reduction. Further, increasing health system complexity led to PCPs withdrawing from hospital care.7

Davis and col-leagues (3) provide useful new data that enhance our un-derstanding of the effects of hospitalists on health sys-tems. In their study of a voluntary hospitalist system at alarge rural nonteaching hospital in Mississippi, theyfound that patients cared for by hospitalists had adjustedhospital stays that were 25% shorter, and costs that were12% less, than patients cared for by nonhospitalist inter-nists. For patients in the highest severity group, these sav-ings were even greater. Annualized, the authors extrapo-late that the hospitalists would have saved $2.5 millionhad they cared for all of the internists’ patients. As withprior studies that found similar reductions in resourceuse (4 –7), these substantial savings were achieved with-out diminishing quality or patient satisfaction. Nor wasthere evidence of cost shifting: hospitalists’ patients wereno less likely to be discharged to home (instead of anotherinstitution such as a skilled nursing facility) than werepatients of primary care internists. We can now state withconsiderable confidence that hospitalists markedly de-crease inpatient costs and lengths of stay with no compro-mise in quality or patient satisfaction.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect. Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea. “If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field. “If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting. “The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.” Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say. Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi. “Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine

John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future. Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care. BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge. <img class="file media-element file-medstat-image-flush-right" height="220" width="220" alt="Dr. Weiner" typeof="foaf:Image" src="https://www.the-hospitalist.org/sites/default/files/styles/medium/public/images/weinerweb.jpg" title="" />Dr. Weiner “The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon. “The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says. Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge. And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task. “There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits. “The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.” Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital. “We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member

SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”