If there is one thing most everyone in healthcare can agree on, it is that too often the information we need is not readily available.
Primary care physicians (PCP) complain that when recently hospitalized patients show up in their office—or, heaven forbid, call the first day after their hospital discharge—they don’t have their discharge information. We often hear that when hospitalists are called to admit an acutely ill patient information is sketchy or incomplete. We hear most hospitalized patients present not only as diagnostic challenges but as “unknowns” with insufficient history and medication information.
A 2006 study by the Common-wealth Fund found that in 32% of outpatient visits or referrals, crucial test results or clinical information were absent and consultation needed to be rescheduled.
In many ways the biggest knock on the hospitalist model is that, despite their better in-house availability, use of resources, or quality of care, hospitalists create another “interruption” in care coordination.
This “voltage drop” didn’t start with hospitalists. It has been around whenever patients are referred to specialists or for surgery—or most procedures, for that matter.
But hospitalists and SHM have seized on this perceived Achilles’ heel and formed coalitions to improve transitions of care and urge better care coordination. While working with many others in medicine, SHM also has had interesting discussions with key change agents not traditionally encountered in healthcare.
With grants from the John Hartford Foundation, SHM has developed state-of-the-art discharge planning tools available on the SHM Web site. And, SHM and Intel have discussed broader strategies for managing information.
In addition, I attended a recent American Hospital Association Leadership Summit and had lunch with Colin Powell, who is active at RevolutionHealth.com—the brainchild of AOL founder Steven Case.
One of RevolutionHealth.com’s projects is to create a widely used personal health record (PHR). This would be a Web database with the patient as the focal point. When a patient has a test, sees a physician, visits an ED, or is hospitalized, that information would flow into an updated record accessible by the patient or physician virtually anywhere, any time.
For hospitalists, this could be a source of complete, up-to-date medication lists, diagnoses, and test results. Hospitalists or case managers could update this PHR at discharge so it is immediately available to PCP or coverage partners, home healthcare providers, or a skilled nursing facility. This type of tool doesn’t require that every physician have an electronic medical record (EMR) and isn’t limited by interoperability issues.
Other strategies are gaining traction. At a recent conference on care coordination sponsored by the American Board of Internal Medicine Foundation (ABIM) in Montreal, Quebec, Canada, Chuck Kilo, MD, MPH, CEO of GreenField Health and The GreenField Group in Portland, Ore., showed how e-mail smoothes transitions and improves information flow.
Those in Dr. Kilo’s practice recognize that, while some professionals may have reservations about e-mails between patients and physicians, there seems less resistance to physicians and hospitals using e-mail to exchange information. With minimal expense and startup costs, PCPs can e-mail patients’ medication records, recent chart notes, and test results to a specialist for referral or a hospitalist for admission.
When the consultant or hospitalist is ready to provide information in the transition back to the PCP, e-mail is a quick solution. It’s not perfect, but it’s immediate. Certainly there are barriers to overcome: HIPAA issues are always important to resolve, and documents converted to PDFs don’t flow into an EMR. But this is a step forward.
These solutions get information to the point of decision when the patient is there and the acute need must be met. For those in the trenches this is good news—a great improvement on the hunt-and-peck paradigm.
In a broader strategic approach, SHM has advocated giving hospitalists a role in defining the standards and measures to be used in assessing performance in transitions of care. In July, SHM worked with the ABIM, the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Agency for Healthcare Research and Quality to develop consensus on transitions-of-care standards. This group included most of the big players in the house of internal medicine as well as representatives from nursing, pharmacy, case management, home health, patients, and families. The American College of Emergency Physicians (ACEP) joined the discourse in August.
At the same time, SHM has been working with the American Medical Association’s Physician Consortium and the National Quality Forum to use standards conceived in consensus to develop measures for transitions of care. The measures would mark either stand-alone performance or performance with specific disease states (e.g., management of diabetes or acute heart failure).
Hospitalists will need resources and tools to give patients the best care and smoothest transitions (and score well on these measures). SHM has developed a Web-based quality-improvement resource room on transitions and continues to work with a broad coalition to improve the discharge process under our Hartford grant.
We add real value for our patients. But our job doesn’t end at the hospital door. Hospitalists recognize their obligation to patients as well those who will assume their care outside the hospital. Whether working on tools with Intel or RevolutionHealth or working with professional societies and organizations charged with developing performance standards and measures, hospitalists and SHM must take an active leadership role.
This is not easy stuff and can’t be solved in one meeting—or even one year.
A few years ago no one was talking much about patient safety, notes past SHM President Bob Wachter, MD, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. That is, until the Institute of Medicine’s 2000 report “To Err Is Human: Building a Safer Health System” and some disastrous medical errors.
Transitions aren’t happening well, and care is sporadic and isolated. This is high on our agenda; SHM and hospitalists are willing to work with any group that will help all of us get closer to a solution. TH
Dr. Wellikson is the CEO of SHM.