Growth of hospitalist programs brings confidentiality, continuity concerns
Growth of hospitalist programs brings confidentiality, continuity concerns
Ethics committees must address unique communication issues
The expansion of hospitalist programs at medical centers nationwide has yielded impressive benefits in terms of reduced costs of care and lowered length of stays, according to recent published studies.
But the use of designated inpatient physicians to assume primary responsibility for admitted patients can have unforeseen consequences for continuity of care, patient privacy, and clinical decision-making, some ethicists are warning.
"There are important ethical issues that people need to understand. And as these ethical issues arise in the hospital, what is best for the patient is for the hospitalist and the primary care provider to work closely together," says Steven Z. Pantilat, MD, assistant clinical professor of medicine in the medical ethics program at the University of California-San Francisco (UCSF) School of Medicine.
According to the Philadelphia-based National Association of Inpatient Physicians, there currently are 6,000-7,000 hospitalists practicing in the United States today. But that number is expected to grow to approximately 20,000 physicians over the next 10 years.
Recent studies have indicated hospitalist programs can reduce hospital lengths of stay by 15%-16% and lower hospital costs by an average 13.4%.1,2
But ethics committees at centers with hospitalist programs need to be aware of the unique needs and ethical dilemmas these arrangements can provoke, say Pantilat and others.
A particular area of concern is patient confidentiality, he notes.
Whose decision stands?
Pantilat and colleagues at UCSF have published several papers and case studies of ethical issues related to hospitalist systems. A key issue that keeps coming up, he says, is whether the outpatient primary care provider’s decision to keep some information confidential should be respected by the inpatient primary care provider — the hospitalist.
In one case they examined, an HIV-positive patient was admitted to the hospital for treatment. Although the outpatient primary care physician knew the patient’s status, the patient did not want the information disclosed — even to his wife and family. However, the hospitalist assuming care for the patient felt duty-bound to inform the patient’s spouse.
"One thing we have focused on in our studies is the issue of confidentiality and maintaining confidentiality when another physician enters the care of the patient in the role of the primary doctor responsible for the care of the patient, not simply as a consultant, but really someone who is primarily responsible for the patient in the hospital," Pantilat explains.
The hospital-based physician may have different ideas about his or her obligations to maintain a patient’s confidentiality vs. a duty to prevent others from being harmed, he says.
"Because they only see that patient while in the hospital, they may view the value of trust and the implications for patient confidentiality differently than the primary care physician might," he speculates. "Specialists might defer to the primary, because they have ultimate responsibility for the patient. But I feel the hospitalist will feel primarily responsible."
In the cited case, neither physician’s position would be wrong, which makes the issue even more complicated.
"HIV is a different situation because in most states, health care providers are permitted to warn [others at risk] but they do not have a duty to warn," he says. "In other cases, like tuberculosis, for example, the physician has a legal duty to notify the health department and warn others at risk."
Rather than attempt to legislate whose position would take precedence, it is more important to have systems in place that foster good communication between the hospitalist and the outpatient physician, he says.
"The closer the hospitalist and the primary care physician can work together, the better for the patient," he says. "If it is an ethical issue, a medical issue, a social issue, in all of those situations — where there are multiple right’ ways to go — to work together to come up with a solution is what is best."
Maintaining communication
Poorly designed hospitalist systems — those without established protocols for ensuring communication between the hospitalists and primary care providers — can significantly detract from a patient’s continuity of care, adds Ronald Greeno, MD, chief medical officer and senior vice president of physician services for Irvine, CA-based Cogent Health Care Inc., an inpatient physician management company.
"As a hospitalist, you have an obligation to communicate with primary care physicians and to do that in a 100%-reliable way," he notes.
The system must be set up so that patient information, case management, and follow-up cannot slip through the cracks. With two separate physicians assuming primary responsibility for the patient, the potential for such an occurrence is heightened.
"If, as the hospitalist, I am discharging a patient home at 5:15 in the evening on a Friday of a three-day weekend, by the time Tuesday rolls around, I am not going to remember to call the [primary care] doctor about that patient three days later," Greeno says. "Then, even if I call their office, and they are with a patient, by the time they call me back, I am in another part of the hospital, etc."
The physicians can play phone tag, then give each other a verbal update, but, by the time the patient presents for a follow-up visit to the outpatient physician a week later, does the primary care doctor remember all of the information conveyed by the hospitalist?
Cogent’s solution to the problem has been to design a standard discharge summary dictated by the hospitalist that is automatically transcribed and faxed to the physician’s office immediately upon the patient’s discharge. The summary has all of the information about the patient’s stay, the medications he or she has been sent home with, and when they will are supposed to present in the office for a follow-up visit.
At the same time, the discharge summary information goes into a central database. A specialized clinical care coordinator is assigned to call the patient 48 hours after discharge to ensure the care plan is in place, that any schedule home health services have occurred, and that patient is in contact with the outpatient physician.
The information in the database also is available to the hospitalist physicians if that patient is readmitted to that hospital or another hospital at a later date, Greeno adds.
"Just that one step, you have to figure out a clear, reliable way to ensure communication and follow-up that provides for good patient care and helps the primary care physician with continuity of care," he states.
Another wrinkle in hospitalist programs is the issue of patients who do something to irreparably damage the patient-physician relationship, says Pantilat.
In outpatient physician practices, if a patient is uncooperative or threatening to the physician or staff, the physician can ethically discharge the patient from the practice.
"The reason we can do that is we don’t have ongoing care that cannot be handled by somebody else," he explains. "I can give the person numbers of other physicians and help them find doctors, but say, Look, I can’t have you back here.’"
But what if a patient threatens an inpatient physician and then comes back to the same hospital for treatment? Perhaps the facilities the patient needs are not available at another institution, and the hospitalist group is the only one providing inpatient care at that facility.
"We don’t have a good answer for that one yet," Pantilat adds. "On one hand, doctors do have that right. But on the other hand, patients need to get appropriate care."
QI efforts strengthened
Though the dual-doctor system may present ethical challenges, there are many ways hospitalist programs improve patient care as well as save money, Pantilat and Greeno note.
Because hospitalists are always at the hospital, it is much easier for facilities to implement and monitor quality improvement efforts.
Cogent’s system monitors the discharge summaries to ensure that patients with specific diagnoses receive the recommended treatments, Greeno says.
For example, the monitoring ensures that patients with heart disease are instructed to take aspirin and that patients who have experienced heart failure are given ACE inhibitors on discharge.
"QI efforts and changes in policy may be easier to implement because you have a smaller group of doctors caring for these patients — and educating them about procedures and policies and ethical issues is simplified," says Pantilat.
Discussions about code status and helping patients with serious illnesses consider implementing advance directives also is an area where hospitalists may fare better than their outpatient counterparts.
Cogent requires its physicians to ask about code status with any patient admitted for a certain diagnosis.
"It is one of the things we look at in our audits of discharge summaries," Greeno says. "For 11 different diagnostic groupings, we look for evidence there was a discussion of the patient’s code status and the result of that discussion. For patients with certain serious illnesses, patients admitted with ischemic stroke or chronic liver disease, etc., we ask the physician to inquire about code status."
Inpatient physicians may fare better during these discussions than the outpatient primary care providers, speculates Pantilat.
"I completely agree that hospitalists, in some way, have a responsibility to bring it up, and, in some ways, not having known the patient or have a long history with the patient may make it easier," he notes. "The hospitalist can explain that questions about code status are a standard part of what he or she does. But if it is a patient’s primary care doctor, the patient may wonder, Why are they bringing this up now?’"
For more information
- The web site of the National Association for Inpatient Physicians (NAIP) contains information about ethical issues related to hospitalist practice and background information on hospitalist programs across the country. www.naiponline.org.
- A supplement publication of the American Journal of Medicine covered the proceedings of a symposium on the hospitalist movement: Pantilat SZ, Wachter RM. The patient-provider relationship and the hospitalist movement. Am J Med 2001; 111(9B). ISSN:0002-9343. Full text available to subscribers at: www.AJMSelect.com.
References
1. Wachter RM, Goldman L. The hospitalist movement: Five years later. JAMA 2002; 287:487-494.
2. Diamond HS, et al. The effects of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med 1998;129:197-203.
Sources
- Ronald Greeno, MD, Cogent Health Care Inc., 2600 Michelson Drive, Suite 1400, Irvine, CA 92612-6529. Telephone: (888) 646-7763 or (949) 399-6000.
- Steven Z. Pantilat, MD, Assistant Clinical Professor of Medicine, 521 Parnassus Ave., Suite C-126, University of California-San Francisco, Box 0903, San Francisco, CA 94143-0903.
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