One recent morning, my grandma awoke with abdominal pain. She was taken to a good, local community hospital and diagnosed with acute ischemic bowel. There are various causes of ischemic bowel, but regardless of cause, getting the right care quickly determines whether such patients live or die.
After speaking with her physicians, I called some friends. A quick discussion with colleagues in radiology, surgery, and gastroenterology helped me know that the right management plan was being pursued. She remained at the community hospital and went to the operating room.
Almost everyday, patients get transferred from the beds of community hospitals to beds in tertiary care centers. These transfers occur for various reasons, but often to allow access to specialists since tertiary care hospitals have nearly every possible type of specialist. Once transferred, the specialists meet and examine the patients and offer recommendations.
Transferring patients is a pain. It costs a lot of money and it’s not efficient. Nearly everything that was done with the first admission is repeated after the transfer. History taking and questioning, admission notes, admission orders, and basic lab tests. All repeated. When the initial evaluation isn’t repeated or carefully reviewed, important things get missed. Since doctors are both busy and human, they don’t always review the large stacks of transfer documents or speak to the transferring physicians.
For some patients, the transfers need to happen. The specialists need to lay their hands on the patients to offer meaningful evaluations. In many other cases, the need to physically transfer these patients is suspect. If they weren’t transferred, however, how would specialists be able to help?
They could do it remotely, of course. If the patient required interviewing, the specialist could use video- or phone-conferencing. If patient interviews weren’t required, the specialist could simply talk with the patient’s current doctor and they would review the data together, verbally or using remote viewing interfaces.
If this were commonplace, it would reduce the need for costly transfers. Further, it would dramatically increase effective access to specialists for patients who either don’t meet local thresholds for transfer or those who cannot be physically transferred. This later category of patients may be too sick to tolerate a transfer or too far from a tertiary care center.
Assuming this system could work, would it be useful and if so, why doesn’t it already happen? Remote consultation is not a regular part of community inpatient care because outside consultants aren’t paid for it. It is not feasible to take busy consultants away from their current inpatient and non-inpatient activities to curbside consult on remote patients for free. When patients and payers begin to see this type of curbside as cost saving and useful, they will start paying for it. Tertiary care specialist groups could then enter into contracts with community hospitals to provide this type of care.
Current models do this for stroke patients that present to community hospitals. The consultant remotely evaluates the patient and helps determine the required level and type of care. Community hospitals that engage in these contracted agreements love the setup because their patients do better and the hospitals get higher ratings and quality stamps. Tertiary centers love it because they not only provide better care to the community with fewer resources, but they acquire an influx of instant referrals. Extrapolating this model to smaller or larger episodes of care would change the way by which patients are managed.
As is the case now within tertiary care centers, an initial phone discussion between the referring and consulting physician helps determine the urgency and level of care required. For many patients, a simple curbside recommendation is sufficient.
“Get a neck MRA. If it’s abnormal, let’s talk again.” For other patients, a simple curbside is not adequate. These patients require a face-to-face consultation.
Discussions between the referring and consulting physicians are the media by which this determination is made and it’s at the core of high-level medical care. Two professions, with different skill sets, come together to resolve a problem. They are able to effectively and efficiently accomplish the task because they speak the same language. This makes it quick and practical – and scalable to other settings.
Would this new type of care be useful? The best evidence of its utility: My grandma. Doctors use this system for their friends and relatives. In fact, there probably isn’t one family member of a doctor who hasn’t benefited from it. When a doctor’s relative gets admitted to a community hospital, the doctor usually first speaks to the primary attending or consultant taking care of his family member. Next, he phones his friends.
If the problem is gastrointestinal, he calls his gastroenterology friend. If it’s a stroke, he gets in touch with a stroke neurologist. This is especially useful when these consultant types aren’t available at the admitting hospital. The outside consultants then review the current plan. If changes are recommended, the plan might be altered at the community hospital. This obviates the need for a physical transfer and is often preferable for all parties. There might be ongoing management discussions between the current care team and the outside consultant or the patient might get transferred.
Implementing this new type of remote care would make some people uncomfortable. Remote care means consultants can’t do what they normally do. They wouldn’t be able to engage in their typical 1-2 hour A-to-Z evaluation of a case. They couldn’t examine these patients face-to-face. The relationships made between doctors and their patients would change. The information given to the remote consultant might not represent the real information – the data the consultant may have gathered had he been at the patient’s bedside.
These valid concerns withstanding, the current system is hardly working well. Too many patients who don’t need tertiary care transfer would benefit from expert input, but don’t get it. Too many patients that could benefit from remote expert input get transferred unnecessarily. In other words, not every medical problem requires the same level and method of care. Sorely needed is a way to better connect experts to patients that is short of throwing the kitchen sink at each patient.
P.S. My grandma is fine.
Adam B. Cohen is the neurology inpatient medical director at Massachusetts General Hospital in Boston, Massachusetts and blogs at The Horse and Zebra.
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