Boost care coordination between ED, primary care

No quick fixes, but process improvements 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, says 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.

Any process or patient-flow improvements that free up time for emergency physicians and PCPs to interact will benefit virtually any ED setting, Carrier says. "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.

For more information, contact the following:

Emily Carrier, MD, MSCI, Senior Researcher, Center for Studying Health System Change, Washington, DC. E-mail: ecarrier@hschange.org.

Tarek Elsawy, MD, Medical Director, Quality Alliance, Cleveland Clinic, Cleveland, OH. Phone: 440-543-9810.