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Bridging the gap between ED and PCP
Reform puts problem area on front burner
There are literally dozens of studies that enumerate some of the problems that plague patients as a result of imperfect transitions of care. According to the National Institute for Health Care Reform (NIHCR), there will be an additional 32 million insured people by 2019, many of whom will seek care in hospital emergency departments (EDs). That makes improving care coordination between primary care physicians (PCPs) and the emergency department more important than ever. In a study of how well and how willing physicians are to communicate with each other, the NIHCR and Center for Studying Health System Change (HSC) found that there are few easy answers to the problems.1
Using phone interviews of 21 pairs of ED and primary care physicians, researchers discovered that real-time communication is best in some circumstances, but could be very time-consuming; that faxes could be of limited use and physicians questioned how carefully they were reviewed; and that shared electronic records could address some problems.
One problem that physicians and their champions often raise is that doctors do not get reimbursed for communicating with another doctor about a patient. While one might expect the good of the patient to trump issues of reimbursement, physicians are people and they will do more readily that which is rewarded. Ann S. O'Malley, MD, MPH, a senior researcher at HSC, has looked at physician perceptions about how well they and others communicate with each other.
In her most recent study2, O'Malley found that physicians think they communicate more often and better than they really do. Tracking some 4,700 physicians, O'Malley and her colleagues asked about perceptions of communications about referrals and consultations. While 69.3% of primary care physicians reported sending notification of patient history at least most of the time, only a bit over a third of the specialists said they always or most of the time received such notification. And while more than 80% of specialists said they always or most of the time send results to primary care physicians, just 62.2% of those PCPs said that was so. The quality of the communications was also lacking, according to the study, which appeared in the Jan. 10, 2011, issue of the Archives of Internal Medicine.
Regardless of the perceptions, O'Malley also mentions the lack of aligned incentives for getting physicians to do better at ensuring patients who are seen in a hospital or by a specialist have their cases relayed efficiently and effectively to their primary care doctors, and likewise that those specialists have all the information they need about a patient when they need it.
"I was not expecting quite the gross differences we found, although we know coordination of care and communication between physicians is lacking in this country," she says.
There are a variety of reasons for the disconnect between perception and reality, along with the lack of incentives to provide great communication. Some of them might include process problems such as physicians thinking something was faxed and it not getting done, or not getting done in a timely manner. Some are physician problems, such as the legibility of notes that are faxed to other physicians. As for the problems with ED physicians in particular, O'Malley says her sample was not large enough to drill down to particular specialists. However, she notes that the sheer busy-ness of EDs and the increased complexity and severity of illness in the patients they see reduces the time they can spend on things like sending notes and phoning other physicians.
But EDs see some of the most vulnerable patients: the old, the very sick, those with multiple conditions, children, and those who have trouble navigating health systems, such as immigrants and the poor, O'Malley says. That makes ensuring good communication and coordination of care even more important.
How do we solve the problem? O'Malley says she hopes reform will change the incentives so that there is some sort of reimbursement available for communication activities. There should also be ways to make such communications automatic and easy.
That is just what Medical City Dallas Hospital is working on, says Bev Cunningham, MS, RN, vice president clinical performance improvement at the HCA facility. While electronic medical records make knowing what has happened to patients easy for physicians who are part of the system, those who are not have more of a problem, she says.
Currently, the hospital is working on a process improvement project that will have primary care physicians phoning whenever they know a patient of theirs is coming to the ED, and the ED calling when that patient arrives. For unassigned patients, Cunningham says hospitalists handle communications. They are also considering a paper note that will be passed on between physicians at shift change.
Journal can smooth transitions
Another option is to create a paper or online journal that helps create smooth transitions, whether to another unit or the back to the medical home. In a study published in the Journal of the Royal Society of Medicine3 in February, Gurdev Singh and his colleagues tested a journal developed by physicians and nurses using the Situation, Background, Assessment, and Recommendation (SBAR) format.
What they developed was used as a checklist for transitions, as an audit tool, and as a teaching tool. Initially only on paper, it quickly morphed to a Web-based tool, which may also address "Meaningful Use," says Singh.
Singh says that the lack of care coordination costs hundreds of billions of dollars per year and causes "a huge amount of harm" to patients and their families. Having timely and reliable communication between settings is the prevailing root cause, he says. The Joint Commission has recognized the importance, requiring "structured methods of transitioning patients." He thinks his study may be one way to address this need.
Rather than using a top-down approach, however, he thinks using a tool that was developed by the very people who will use it will result in better buy-in.
While noting that vulnerable populations are at particular risk from bad transitions, Singh thinks that "all groups are deficient" in this area. He hopes tools like his will help alleviate that problem.
1. Carrier, E, Yee T, Holzwart RA. Coordination Between Emergency and Primary Care Physicians. http://www.nihcr.org/ED-Coordination.html.
2. O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011 Jan 10;171(1):65-7.
3. Singh R, Roberts AC, Singh A et al. Improving transitions in inpatient and outpatient care using a paper or web-based journal. JRSM Short Rep. 2011 Feb 3;2(2):6. Available free online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046565/
Bev Cunningham, RN, MS, Vice President of Clinical Performance Improvement, Medical City Dallas Hospital, Dallas, TX. Telephone: (972) 566-6724.
Ann O'Malley, MD, MPH, Senior Researcher, Center for Studying Health System Change, Washington, DC. Telephone: (202) 554-7569.
Gurdev Singh, Director, UB Patient Safety Center, Family Medicine Research Institute, State University of New York, Buffalo, NY. Telephone: (716) 898 5640. Email: firstname.lastname@example.org.