Discontinuity with source material. Most digital canvases, like Muse and Kinopio, aren’t designed for the workflow we’ve been discussing. They’re not tightly integrated with a reading environment. If you just paste plaintext snippets into them, the resulting cards aren’t linked to the source document

Initial resistance to the hospitalist movement among physicians often focused on the unavoidable discontinuity in care created by the model and the potential loss of information across the hospital threshold.45,49-52 Effective hospitalist programs have created mechanisms to mitigate the impact of this discontinuity, including calling primary care physicians on admission and discharge, faxing daily progress notes, and encouraging primary care physicians to visit or call their hospitalized patients. Though some concerns about information transfer linger, 2 recent surveys suggest that most physicians now accept the hospitalist model. In a national telephone survey of 400 internists, 51% (204) thought hospitalists might provide better care and 46% (184) thought patients might get more cost-effective care. Although 73% were concerned about the impact of hospitalists on continuity, physicians with hospitalists in their community were more approving.10 In a survey of 524 California primary care physicians, physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and most (55%) thought that hospitalists increase inpatient efficiency.11 In both surveys, primary care physicians stated their belief that patients generally preferred to be cared for in the hospital by their regular physician. Surveys of both generalists and specialists at Park Nicollet showed high levels of physician satisfaction several years after the implementation of a hospitalist program.28

A major early concern was that patients accustomed to having their primary physician as their inpatient attending would not accept hospitalists.45 In general, however, surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians28,31,32 or by traditional academic ward attendings.18,21 We have postulated that patients may be willing to trade off the familiarity of their regular physician for the availability of the hospitalist.45

“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.”

Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specializa-tion and full-time hospital pres-ence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing sys-tems (e.g., handoff protocols and post-discharge phone calls to pa-tients) to mitigate harm from dis-continuity, it remains the model’s Achilles’ heel.

As with anymajor transition, the medical community must con-tinually reevaluate the new approach to ensure thatany possible discontinuity in care is outweighed byimproved clinical outcomes, lower costs, better edu-cation for physicians, and greater satisfaction on thepart of patients.