Information is everything, communication is the key.
Recently, we were contacted by the medical director of a subspecialist fellow’s practice at one of our affiliated hospitals.
She wanted to discuss ways to improve communication between our practices, and expressed considerable frustration about the information received in consultation requests from the providers in our practice sending patients their way.
She noted that they had “read-only” access to our electronic health record (through an information-sharing agreement between our hospitals) and said that they were able to see the consult order in the system (which has a section for clinical comments), as well as read the provider’s notes to glean information about why the patient was being sent to see them.
Apparently the fellows at her practice were frustrated about the lack of clarity in the consultation requests, not being able to extract from all of this what the clinical question being asked of the subspecialist was.
We had a long discussion about how important this was and how her fellows spent enormous amounts of time reading through the chart to find out what the patient’s complaints were, what their past medical history was, what interventions had been tried for the specific complaint, and what specifically the provider sending the patient to them was asking their assistance with.
This is perfectly reasonable; there is a real expectation that when you refer to someone that you clearly delineate your question to them, to make it easier for them to help you care for your patient.
This is an art form, being able to wisely use your consultants, to know how to engage them to help you improve the condition of your patients. For our interns and residents this is part of the learning process, and in looking back at their consultation requests we found the quality and clarity of the consult question at times lacking, at times nonexistent.
This is an education deficit, a gap in what we are teaching them, but we hope to help them learn this process as they continue to grow as clinicians.
As we talked over this problem, we came up with a plan for ways to continue to educate our providers on the best way to communicate with consultants and ask them an appropriate clinical question, to help make their lives easier as they see our patients in their practice.
I then mentioned to the medical director that, in the nearly 20 years that I’ve been at this practice and we have been sending patients to them, there has been no mechanism in place for them to communicate back to us. We send patients to them, and they disappear into the black box of the hospital down the street.
No letters, no emails, no phone calls.
Patients return and we ask them what the specialist did, what they tested them for, what they told them to do, what they gave them to try. The response is usually “they did some tests, they gave me some medicine, but I can’t really recall the details.”
Their hospital still has no outpatient electronic health record, so the fellow’s notes are typed as simple word-processing documents, printed, and saved to a paper chart.
They are complaining that they have read-only access to our electronic health record, but read-only access is better than no access. Never a thought about sending your consultation note back to the requesting provider.
Seems like an obvious deficit, something missing from the consultation process, which would really allow us to take better care of our patients.
We talked about different ways to improve this problem, and over the course of the next half hour we jury-rigged a process whereby their practice administrator would remind the fellows to print a copy of their notes for bulk faxing to our practice once a week.
Someone at our end would go through those faxes, identify the referring provider, and transport the paper to their mailboxes, ultimately to allow them to be reviewed and then scanned into our electronic health record.
Not very technologically savvy, and likely to quickly be forgotten as the busy fellows go about their days.
Pretty damn clunky, if you ask me.
This is, of course, a temporary fix, albeit an ugly one; there are plans in the works for them to get the same electronic health record as us about a year from now, so we hope that at least then we will be able to see their consultation notes.
The consultant rendering the opinion that you never hear about is not much help at all.
Collecting all of the far-flung information that is generated on our patients when they are outside of our physical practice is one of the major goals of a patient-centered medical home. An office visit goes much more smoothly when you have the notes from a consultant the patient has seen near their home, or the inpatient records of a recent hospitalization when they were in Florida, or the results of a blood test or urine culture done at an urgent care center several days earlier.
On our inpatient service, each medical team is assigned a transitions coordinator, who rounds daily with the team to find out what their needs are, what they can assist with in reaching out to collect that unavailable information and bring it where it can do some good.
This is just the kind of support that is absolutely critical to making team huddles productive in a patient-centered medical home, that there is someone who can do the legwork to run those things down.
This is about practicing up your license. The days are gone (or should be) when an intern should have to chase down information from multiple different locations. We should be given the support to add these members to our team so that the doctors can go on doctoring, and spend less time doing these administrative tasks.
Providers will be more satisfied with their lives in the outpatient practice and, ultimately, patients will get better care.
As we move ahead transforming the health care system in this country, many different players are coming to the table to try and help us fix all of the things that are broken. Whatever models we end up with, be they patient-centered medical homes or accountable care organizations, or some other set of initials, having the resources necessary to do care coordination and transitions of care are critically important.
Without this, the system will only continue to crumble, as care continues to be duplicated, fractured, dissipated and uncoordinated.
Information without communication is uninformative.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.