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Study finds ways to boost care coordination between emergency and primary care providers
No quick fixes, but process improvements and alternative communication modes can help
If improved care coordination is integral to bending the health care cost curve, then the interchange between emergency physicians and primary care practitioners (PCPs) is in need of significant improvement, according to a new study on this issue conducted by the Washington, DC-based Center for Studying Health System Change (HSC) for the nonprofit National Institute for Health Care Reform (NIHCR).
The report, Coordination Between Emergency and Primary Care Physicians, is based on telephone interviews with 41 pairs of emergency physicians and PCPs who were matched so that researchers could obtain the perspectives of both specialties working in the same hospital settings. (See "Editor's Note" below for link to report.) The study concludes that poor communication and poor coordination undermine effective patient care, and that there are no quick fixes to these problems. However, the authors stress that there are things ED managers can do to address existing barriers while at the same time reducing inefficiency, waste, and errors.
Unique challenges surface in the ED
Emily Carrier, MD, MSCI, a co-author of the study and a senior researcher at HSC, decided to look into the issue because, as an emergency physician herself, she has experienced firsthand the challenges of trying to coordinate with PCPs, but she has seen little research on the subject. "I saw that there had been a lot of thinking about how care can be better coordinated, but it hasn't really focused on this particular interface, so I wanted to fill in this gap," she explains.
Patient encounters in the ED are distinctly different from other care encounters in a number of ways that add complexity to the care coordination piece, says Carrier. "If you think about the classic PCP-specialist interaction, the PCP might identify the need for a specialist consultation, he might help the patient to schedule it, and prepare some information to be sent to the specialist's office in advance of the visit," says Carrier. "Then, after the evaluation, the specialist might send the information back to the PCP and the next time he looks at the file, he will read it over."
Typically, everybody knows what is going to happen next in such a situation, but that is not always the case in the ED, stresses Carrier. "Many encounters in the ED are unplanned. Further, the patient may go there on his own, or he may be sent there by someone who is not the PCP," she says. "ED visits may occur at any time of the day or night, and they can involve a broad spectrum of illness ranging from something very minor to something that is critical."
All of these factors make communications and care coordination more challenging for both emergency physicians and PCPs, says Carrier, and both sets of providers expressed frustration to researchers about the time and inconvenience required to perform care coordination tasks. "Many felt this task doesn't bring them very much in terms of reward, and people also felt that the extra effort doesn't decrease their risk in any meaningful way," she says.
There is no question that care coordination and communications are significantly streamlined in hospital-based health systems that have electronic health records (EHR) that are widely used by community PCPs, but Carrier emphasizes that the EHR is not a silver bullet.
"In most cases, EHR systems are not designed to facilitate a rapid overview and synthesis of information," she says. "They are very good at storing information and they are very good at retrieving information if you know what you are looking for, but if it is 2 o'clock in the morning and you've got to find out what a person's cardiac history is, the EHR can definitely be challenging."
In particular, Carrier explains that for those patients who could most benefit from care coordination older patients and the chronically ill you could be wading through screen after screen on a voluminous EHR, and it can be very difficult for either an emergency physician or a cross-coverage provider to figure out what is going on.
Time facilitates interactions
There are steps EDs can take to cut through such quagmires, but the most effective solution for one ED will not necessarily work well in another, says Carrier. "Let's say you work in an urban safety-net institution, and most of your patients are getting care through an ambulatory care clinic that is also part of your system," she says, noting that communicating back and forth isn't a big issue in this setting. "In that instance, the best [way to improve] care coordination might be through a proactive approach of setting up meetings between department leaders and coordinating ways to facilitate follow-up visits."
This type of solution would not, however, work well for an ED in a suburban setting that is surrounded by many small, independent PCP practices, observes Carrier. "There is no way you are going to get everybody at the same table, so the first challenge in this instance would be figuring out how you are going to talk to people," she says. (Also, see "Consider relationship-building activities & alternative communications strategies to boost care coordination, quality," below.)
Any process or patient-flow improvements that free up time for emergency physicians and PCPs to interact will benefit virtually any ED setting, notes Carrier. "We see many practices that reward physicians for having a short LOS (length of stay), but sometimes making a discharge stick takes time; it takes making that extra phone call, making sure the patient has a safe place to go, or making sure that key information that needs to get passed along is passed along," she says. "These steps can be very frustrating for emergency physicians, and many of them complain, accurately, that their efforts are not rewarded."
However, there are so many different care circumstances that occur in the ED that you can't address the issue of care coordination with simple incentives, observes Carrier. Further, she notes that incentives can lead to unintended consequences. "If you decided to reward emergency physicians every time they communicate directly with a patient's PCP, that would probably lead to a lot of unnecessary calls related to lower back pain, ankle sprains, and things like that," she says.
Use protocols to drive care coordination
Recognizing that some diagnoses require more care coordination than others, the Cleveland Clinic's Quality Alliance, a consortium between the organization's employed and private-practice physicians, is developing condition-specific guidelines for the sharing of medical information between the Clinic's various affiliated offices, institutes, and hospitals, explains Tarek Elsawy, MD, an internist and medical director of the Quality Alliance.
"For certain diagnoses, such as congestive heart failure (CHF), for example, there is a really high rate of readmissions and people shuffling back into the ED," says Elsawy. "So one of the things we are trying to do is develop certain protocols that will make it part of the evaluation process that we use in terms of how well the ED physicians are getting back to the PCPs, and making sure the patient has follow-up with his PCP following a visit to the ED."
Many of the physicians affiliated with the Cleveland Clinic are already using the organization's EHR, so they have access to any patient labs, X-rays, or other studies in real time, notes Elsawy. "In a lot of cases, that is half the battle because many times patients aren't exactly sure what tests they have undergone, let alone what the results of those tests were," he says.
The Quality Alliance has also begun to track those patients who use the ED frequently to see if there is a portion of their care that is missing, whether that involves gaining access to a PCP or perhaps another resource," explains Elsawy. "Let's say that we find a patient who has been back and forth to the ED three times with the same diagnosis," he says. "What we are trying to do is coordinate with the patient's PCP to get him set up so that he uses the CHF clinic as a means of regular follow-up rather than just going back to the ED all the time."
Initially, the Quality Alliance is focusing its attention on those conditions that have the highest impact in terms of patient readmissions, so conditions like CHF, chronic obstructive pulmonary disease, and pneumonia are being targeted first, says Elsawy. "Most of the EDs are already using protocols for CHF, but what are missing are the handoffs," he says. "If a patient goes from the ED to the hospital, that is one transition, but one of the other things we are working on is making sure that patients who have been discharged from the hospital get back to their appropriate PCP or CHF clinic in a timely fashion to prevent them from repeating the cycle all over again. That is the process we are trying to follow through."
Elsawy acknowledges that just like other providers, ED physicians don't generally favor adding steps or tasks to their workflow, but they nonetheless understand the rationale behind what the Quality Alliance is trying to do, and they are involved with the process. "What we are doing is an absolute transition point to developing an accountable care organization (ACO)," he says. "If we all speak the same language and have the same expectations in terms of the guidelines themselves and how to implement them, then I think that will take us a long way toward what will be an ACO."
Editor's note: To access Coordination Between Emergency and Primary Care Physicians by Emily Carrier, MD, MSCI, Tracy Yee, PhD, and Rachel Holtzwart, visit this link: http://www.nihcr.org/ED-Coordination.html.
Emily Carrier, MD, MSCI, Senior Researcher, Center for Studying Health System Change, Washington, DC. E-mail: firstname.lastname@example.org.
Tarek Elsawy, MD, Medical Director, Quality Alliance, Cleveland Clinic, Cleveland, OH. Phone: 440-543-9810.
Consider relationship-building activities, alternative communications strategies to boost care coordination, quality
If you work in a health care system where primary care practitioners (PCPs) are willing to communicate via text pagers, that can facilitate care coordination with the ED, explains Emily Carrier, MD, MSCI, a senior researcher at the Center for Studying Health System Change (HSC) in Washington, DC, and co-author of the HSC report, Coordination Between Emergency and Primary Care Physicians. However, she stresses that there has to be buy-in from everyone involved, and there are limitations to what you can accomplish via text.
Further, there are always privacy concerns when you use texts, pages, or email to communicate, and unless you receive a fast response, there is no way to be sure that the intended recipient received your communication, notes Carrier. "If you have to follow up [one of these electronic messages] with a phone call, that eliminates the benefit of having an alternative communications modality," she says.
Some hospitals have also found that scribes, who are generally charged with documenting care tasks into the medical record and sometimes properly coding them as well, are also often ideally suited to contacting PCPs or other providers after one of their patients has been seen in the ED. "They can be incredibly helpful in taking on the burden of those 2nd or 3rd pages ... and they can facilitate getting in touch with whatever PCP you need to speak with," says Carrier, an emergency medicine physician who has personally worked with scribes in this way. "Scribes are becoming more popular. They are sort of a low-tech, old-fashioned solution to a lot of different problems that people are having with electronic health records (EHR)."
Having a conversation with a PCP or other provider may seem like a simple task, but as busy as providers in all settings are these days, Carrier emphasizes that making that connection can be quite challenging. "Each of these interactions, taken alone, seems trivial and not a lot to ask of an emergency physician," she says. "But in practice, it involves dialing a number, and then you get a voice mail, and then you sit on hold for three minutes before reaching an answering service. Then you are put on hold again, and the whole cycle repeats."
Another old-fashioned solution involves setting up regular meetings or other joint activities where PCPs and emergency physicians can establish stronger working relationships.
"When putting together the report, we heard a lot about how emergency physicians and PCPs were seeing each other a lot less than they used to," she says, noting that with the advent of hospitalists, PCPs are less likely to do rounds at hospitals, and emergency physicians have fewer opportunities to interact with them.
"We spoke with older providers who remembered when they used to be in the ED almost daily to evaluate patients who were going to be admitted or to write admission orders," says Carrier. "That kind of interaction where you get to know people and determine who you trust doesn't happen as much as it used to."
Making sure that both PCPs and emergency physicians are represented at interdepartmental meetings and committees is one way to create opportunities for interaction, but more informal gatherings can serve this purpose as well, says Carrier. "We heard about one physician who takes care of children with disabilities ... and wants to be involved with every detail of their care, whether they are in a specialist's office or the ED," she says.
"Consequently, this physician plays on the soccer team of the main ED his patients go to, and he says that helps tremendously," adds Carrier. "The emergency physicians know his name if one of his patients comes in, and they know he really values a phone call, so even if it is a hassle, they are more likely to make that call, and they know he will call right back."