Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.
“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”
There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.
“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”
EHR-Facilitated Calls
At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.
When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.
“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.
He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.
Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.
“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH
Tom Collins is a freelance writer in South Florida.
Reference
Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.
Sometimes, Communication Outside the Hospital Is the Problem
Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.
The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.
It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.
“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”
He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.
Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.
“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”
Setting up the right system is the key—on both ends, Dr. Ejnes says.
“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”
— Thomas R. Collins