By Jennifer Larson, contributor
March 11, 2011 - Here’s a common scenario that happens in communities all over the United States:
A patient arrives in the hospital emergency department (ED), in pain, disoriented and unable to completely answer a nurse’s questions. The ED staff members have trouble tracking down the patient’s primary care doctor and are dubious about whether the patient will seek follow-up care after being discharged. Later, the patient’s regular doctor becomes frustrated by what he sees as an incomplete record of care from the ED.
This type of situation often leads to frustrated physicians and other staff members on both the ED and the primary care side of the equation. And haphazard communication between them can undermine the delivery of the most effective care, according to a new research brief from the National Institute for Health Care Reform that included interviews with 21 pairs of physicians.
Titled “Coordination between Emergency and Primary Care Physicians,” the qualitative study noted that not enough attention has been paid to care coordination for patients treated in the emergency department. Coupled with poor communication, “duplicative treatment and misapplied treatment” are often the result.
And because of the growing prominence of advanced practice nurses, especially in primary care, the study’s results are applicable to them, as well.
“This is definitely not just related to physicians,” said Laima Karosas, Ph.D., a nurse practitioner and a regional director for the American Academy of Nurse Practitioners.
“Care coordination is a huge piece that is just not done well,” she added.
Barriers to good communication
In today’s health care arena, everyone is busy, and there are many demands competing for time and attention, noted Emily Carrier, M.D., an emergency physician and co-author of the brief. That’s especially true of the ED and primary care settings.
It might seem like it should be easy for one provider to just pick up the telephone and call another to get information about a patient, but it’s not that simple. And indeed one commonly cited barrier to effective communication between emergency department physicians (and nurses) and their counterparts in primary care is the time-consuming nature of communicating by phone.
“It can take hours and involve many attempts and many interruptions,” Carrier noted.
Another barrier is the limitation of asynchronous methods of communication, such as email, text messages, and faxes. Without real-time communication, there’s no opportunity for two people to share details that aren’t written down or to ask questions about information contained on the page.
“Calling people is very difficult,” said Karosas, ticking off the list of communication troubles that she’s encountered. “Faxes get lost, faxes don’t get through.”
“Physicians had little confidence that faxes were carefully reviewed by their intended recipient and often reported that faxed records were poorly organized and difficult to decipher,” wrote Carrier and her fellow authors. They also wrote that there were concerns about liability for the sender of a text message or email.
Other barriers to coordination include:
• Lack of time and reimbursement;
• Limited role of cross-covering providers;
• Changing interpersonal relationships; and
• Risk and liability concerns.
When the ED providers and the primary care providers don’t have open, reliable communication avenues, it becomes more difficult for all of them to provide the best care for their patients. An emergency physician may not be able to track down the right primary care provider to ask about ongoing treatment for patients who present in the ED. A nurse practitioner might be unable to find crucial information when her patients return to the practice (or to a nursing facility) after being discharged from the ED because the lab results or discharge summaries are incomplete.
They often have to order tests or labs that would be unnecessary if better avenues for communication were in place. That can be both costly and time-consuming.
“It’s easier sometimes to draw new [bloodwork] than to get paperwork,” Karosas confirmed.
EMRs: A potential solution?
Is there a way to improve communication between emergency departments and primary care?
There may not be one easy, surefire solution to the communication problem. The study’s authors wrote that a “much broader commitment to interoperable information technology, investments in care coordination and malpractice liability than currently envisioned” is needed.
A shared electronic medical record (EMR) system is often proposed as a solution that could address some barriers. But the study’s authors wrote that it could “leave other key problems unresolved.”
“What might work brilliantly in one setting might not in another,” Carrier explained.
For example, a large academic medical center in an urban area might experience significant benefits from a shared EMR system that’s connected with their network of affiliated providers in the area. But in a rural area, a small hospital might be surrounded by a loose group of small independent practices. Even if everyone had an EMR system, they might not use the same type of system. They still might not be able to gain access to each other’s records and files when they needed to.
“It’s not an automatic guaranteed solution to their problem,” said Carrier.
But Karosas said she believes a secure, password-protected EMR system that would allow doctors and nurses to access crucial information about a patient, such as lab and test results and medication dosages, could go a long way toward improving care coordination in many situations. If more hospitals and facilities worked together to cooperate on the implementation and usage of a standardized system, “that would help tremendously,” she said.
“I think that’s the way to go,” she added.
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