In the most recent issue of the New England Journal of Medicine, Dr. Thomas Bodenheimer defines the coordination of medical care as “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” Or, to put it in layman’s terms: doctors working together to get things right.
The value of this sentiment should be self-evident, but the coordination of medical care is more complex than it initially seems—even when discussing admittedly uncomplicated concepts. Consider the “hand-off,” that transitional moment when a patient is passed from one provider to another (e.g. from primary care physician to specialist, specialist to surgeon, surgeon to nurse, etc)– or is discharged This transition is unavoidable—as Bodenheimer points out, modern health care necessitates a “pluralistic delivery system that features large numbers of small providers, [which] magnif[ies] the number of venues such patients need to visit.” 21st Century medicine is too complex for one-stop shopping.
Inescapable though it may be, the hand-off is fraught with pitfalls. As Quality and Safety in Health Care (QSHC), a publication of the British Medical Journal, noted in January, the simple transition of a patient from one caretaker to another represents a gap that is “considered especially vulnerable to error.”
Even the most common hand-off—your standard referral from primary care physician to specialist—is not risk-free. As Dr. Bob Wachter recently noted in his blog, “in more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation.” Sadly, the radio silence goes both ways: “in one-quarter of the specialty consultations,” Wachter says, “the primary care physician received no information back from the consultant within a month.”
These missteps are indicative of what can go wrong during the hand-off, such as, according to QSHC, “inaccurate medical documentation and unrecorded clinical data.” Such misinformation can lead to extra “work or re-work, such as ordering additional or repeat tests” or getting “information from other healthcare providers or the patient”—a sometimes arduous process that can “result in patient harm (e.g., delay in therapy, incorrect therapy, etc).”
Bodenheimer points out other troubling statistics that speak to the
problems with fragmented, discontinuous medical care—and that extend
well beyond the physician-specialist back-and-forth. Indeed, poorly
integrated care is evident across the spectrum of medical services. In
the nation’s emergency rooms, for example, 30 percent of adult patients
that underwent emergency procedures report that their regular physician
was not informed about the care they received. Another study “showed
that 75 percent of physicians do not routinely contact patients about
normal diagnostic test results, and up to 33 percent do not
consistently notify patients about abnormal results.” And an academic
literature review concluded that a measly “3 percent of primary care
physicians [are] involved in discussions with hospital physicians about
patients’ discharge plans.”
If you’re sensing a pattern here, you should be: most of the gaps in
care are failures of communication involving primary care physicians.
That’s because, at least in theory, primary care docs are the
touchstone for patient care—the glue that holds it all together.
But primary care has become an increasingly precarious occupation. The
problem is that, relative to specialists, PCPs do a lot more for
relatively little pay. And they are expected to do more each day.
Bodenheimer notes that “it has been estimated that it would take a
physician 7.4 hours per working day to provide all recommended
preventive services to a typical patient panel, plus 10.6 hours per day
to provide high quality long-term care.” So it should come as no
surprise that “forty-two percent of primary care physicians reported
not having sufficient time with their patients.”
With such a heavy time-crunch, it’s not surprising that some things can
fall through the cracks—like follow-ups, double-checking, and generally
going the extra mile (which really shouldn’t be extra at all).
Making things worse is our fee-for-service system, which, as Dr. Kevin Pho (a.k.a.blogger KevinMD) notes,
pressures “primary care physicians to squeeze in more patients per
hour,” and thus encourages a short attention spans vis-à-vis
individual patients. The volume imperative is strongest for PCPs, who
make significantly less money than do their specialist peers. As Maggie
has pointed out
in the past, primary care doctors can expect to pull in—at the high
end—just under one-third as much as surgeons or radiologists.
Predictably, the all-work-little-reward life of PCPs is increasingly
unsexy to newly minded doctors. Kevin notes that “since 1997, newly
graduated U.S. medical students who choose primary care as a career
have declined by 50 percent.”
It’s clear that we have a systemic problem that makes hand-off mix ups
more likely: PCPs are crunched for time, desperate to max out patient
volume, and their ranks are dwindling. Is it any wonder that they can’t
provide the “medical home” that reformers talk about?
This is a recipe for disaster that needs to be addressed. There are
options: We can reform the fee- for- service system, perhaps by
introducing payments for effective care coordination. We can create
financial incentives (such as loan forgiveness) for med students to
choose primary care. We also should have primary care physicians work
in teams more often, from the very beginning of a patient relationship,
thus allowing them to share the load and watch each others’ backs.
But for all that these ambitious changes hold promise, the hand-off
will always exist—which means reformers need to dig deeper and develop
protocols at the operational level. Luckily, they’re doing just that.
Kaiser Permanente, for example, has created a procedure meant to
formalize communication between health care teams when a patient is
transitioning from one provider to another. It’s called SBAR—which stands for Situation, Background, Assessment, and Recommendation. QSHC delves deeper into what this actually means:
“first clarifying the situation—for example identification of one’s
self, unit, patient, room number. Then, pertinent background
information related to the situation is communicated, which may
include, but is not limited to, the admission diagnosis, list of
current medications and most recent vital signs. This is followed by an
assessment of the situation and a recommendation of what to do. In
addition, other strategies to improve communication during
discontinuity include use of face-to-face reports, use of interactive
questioning, ‘read-back’ technique [repeating information aloud for
confirmation] and emphasizing the importance of keeping information up
to date.”
According to a 2006 story
in the Pittsburgh Post-Gazette, SBAR has shown some promise, and not
just at Kaiser. At OSF St. Joseph Medical Center in Bloomington, Ill.,
for example, “cases of harm to patients fell by more than half in the
year after the SBAR program was implemented in October 2004.”
It may seem laughable that the big solution for the hand-off is…a
script. But don’t doubt the power of simplicity—and don’t underestimate
the absence of the obvious. A 2004 study
in the Annals of Emergency Medicine, for example, found that “formal
introductions of one’s self and one’s role on the team are not
routinely practiced when seeing new patients.” No one, not even elite
doctors, are above brushing up on the basics.
The problems with hand-offs aren’t limited to hellos, however; the
goodbyes can be just as difficult. Patient discharge is one of the most
hazardous transitions—after all, it’s the hand-off of sick people from
medical professionals to, well, themselves.
As Wachter and Dr. Kaveh Shojania note in their 2004 book, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, patients are often on their own
once they leave the hospital: “it’s up to them to obtain and take their
meds, observe any physical precautions, and make follow-up appointments
with their primary care physicians or recommended specialists.” Not all
patients can manage to do this successfully, particularly elderly ones.
Unfortunately, in recent years, old folks have been increasingly rushed
out of hospitals thanks to Medicare reforms. In 1983, reformers sought
to contain Medicare costs by using diagnostic related groupings
(DRGs)—essentially a best practices guidebook for distinct sets of
diseases—to set fixed reimbursement rates for particular conditions. By
fixed rates, I mean that hospitals would get paid the same flat rate
for treating say, a heart attack, regardless of how long a patient was
hospitalized (up until that point, reimbursement had been tied to
length of stay). This prospective payment system encourages hospitals
to shorten hospital stays, for obvious reasons.
This system might sound heartless, but don’t be too hard on prospective
payments; so much of our health care costs come from doing too much in
hospitals that it makes sense to have a mechanism for imposing
efficiency on inpatient care. But at the same time, some of our most
vulnerable citizens get ousted from hospitals sooner than their
predecessors. According to Seniors Solutions of America, in 1968,
patients age 65 and older stayed in the hospital an average of 14.2
days. By 1982, that was down to 10.1 days. Today it’s only 6.4 days.
How to help ease these ever-more abrupt hospital departures? Wachter
calls our attention to Eric Coleman, a geriatrician at the University
of Colorado who’s created a model called the “Care Transitions
Intervention.” The premise is that patients should have a “transitions
coach” to “help patients through the post-discharge period.” The coach
would help “prepare patients for their next clinic visit, assist with
medication reconciliation (particularly at home, where medications are
often scattered all over the house), make follow-up phone calls, and
serve as a single point of contact for the patient.”
The key word here is “prepare”—the coach doesn’t do the patient’s dirty
work; he or she essentially serves as a post-discharge consultant.
Patients are trained to care for themselves—so instead of, say, calling
the physician, the coach will educate a patient on the best way to
approach said physician after they’re discharged. Coleman’s model is
currently being tried out by “77 organizations, including health plans,
hospitals, home care agencies, and physician groups.”
Like solutions for handling inside-the-hospital transitions, Coleman’s
coaching system is remarkably simple: its basic premise is that the
best way to have a good experience after receiving medical care is to
have some help. This interpersonal dimension of medicine is absolutely
crucial to managing the hand-off. Face-to-face communication is the key
to clarity, both between doctors and their peers and between doctors
and patients.
I’d be remiss if I didn’t mention the critical role that technology can
play in optimizing the hand-off, however. Electronic medical records
would be a huge help in streamlining, automating, and consolidating so
much of the information that gets confused in transitions.
Unfortunately, Bodenheimer reports that “in 2005, only 15 to 20 percent
of physicians’ offices and 20 to 25 percent of hospitals had
implemented electronic medical record systems.” This is a problem, as
electronic records have huge potential. The Post-Gazette notes that
Brigham and Women’s Hospital in Boston uses a computerized sign-out
system while “Kaiser has developed a Nurse Knowledge Exchange computer
program, which allows departing nurses to create customized electronic
reports on patients for the incoming nurses, such as lab results or
medication changes.” This is good stuff.
But experts agree that, technology or no, it all comes down to
communication. Primary care physicians, specialists, even
patients—everyone needs to be on the same page. In the end, the problem
might be with the very concept of the hand-off, which frames health
care as a series of distinct, unrelated stages. Medical professionals
should continue to re-think this model and realize, to paraphrase
Kaiser’s Michael Leonard, that health care isn’t a series of
self-contained episodes; rather, “we are all in the same movie”—and the
point is to ensure that it’s not a tragedy.
What perfect timing. I got an email the other day from our hospital, that now gives the primary care docs the option of opting out of a phone call, day or night, notifying them that their patient was/is being admitted to the hospital by the hospitalist service.
There are many primary care docs out there that don’t want to be interrupted by the ER doc or the hospitalist with an update or a phone call because they are either sleeping (middle of the night), or they are too busy in clinic to stop what they are doing to come talk to their fellow colleague.
It’s the nature of the beast that the beast created. Welcome to third party medicine.
Another recent article in NEJM(http://content.nejm.org/cgi/content/full/356/26/2665) addressed a related problem in teaching hospitals: handoff of care between residents. The current RRC requirements for resident work weeks make a large number of handoffs of complicated patients inevitable.
Niko-Thanks.
This issue demands MORE than just improving communication.
I am convinced that some(perhaps much?)of this has to do with the failure of modern bio-medicine to accept a holistic scientific model.
I can assure you that many bio-medical specialists and sub-specialists simply aren’t trained or don’t believe that one part of the body(including mind) affects the other or the whole.
Seems obvious to me and my many holistic colleagues. I personally call this the overdue return of the “MACROSCOPE”
Dr. Rick Lippin
Southampton,Pa
Ahh yes, I hear the lovely chimes of economics in medicine once more. Doctors schedules are so busy because that is what is needed to make ends meet, now they don’t have time to do some of the VERY important (though completely unreimbursed) activities related to the art of medicine. Unless of course they would like to give up all sovereignty to become a medical machine with no other meaningfulness in thier life. Oh or we could change the system.
Chris Johnson–
Thanks for your comment.
One hopeful sign: I’m told that medical schools are now teaching courses that focus, specifically, on “the hand-off”–which can only be good.
If residents are going to work more reasonable shifts (which I think they should) that does mean more hand-offs. And learning how to do it should be part of the art/science of medicine.
Hi Happy Hospitalist–I agree that “it’s the nature of the beast the beast created.”
We’ve got trade in the beast that designed this system for a wiser, more practical and more imgaginative beast.
It can, and eventually, will be done (Necessity is the mother of invention.)
You won’t believe the mix-ups and lack of communication that went on during my wife’s nightmare stay at “America’s Best Hospital”
http://adventuresincardiology.wordpress.com/
” After surgeons had permanently removed my wife’s pacemaker during the open-heart surgery to replace the valve that had been inadvertantly destroyed earlier in the day, a man in scrubs came in the room and began moving her bed sheets around and pulling on wires. The nurse and I looked at each other. I asked him who he was, but he ignored me and kept poking around. The nurse became alarmed and demanded to know who he was and what he was doing. He was there, he said, to adjust the settings on her pacemaker.”
As has already been noted, this is almost completely a function of our reimbursement system. Docs are too busy to fit this important, time consuming aspect of good care into their schedule.
When your schedule is packed with patients (the only way you get paid) you simply do not have time to be playing phone tag, leaving messages, sending pages, looking up labs, reviewing charts, or discussing patients with other doctors.
So “hand-offs,” obviously important, get marginalized.
I would fully agree with the last comment. The problems in medicine as it currently exists can largely be traced back to the way services are reimbursed and the fact that the end payors, the patients, are not the ones who decide the value of those services. Somehow we have magically and mystically decided that surgery is a more valuable service than medical treatment, even in circumstannces where the outcome may be the same! The result is that the undervalued services of most primary care and psychiatric services are becomng increasingly less availible. The result of this is that in a normal market, the prices these providers would command should rise, but they haven’t. Why? Because everything is tied to RBRVS which was flawed from the get go and attempts to fix it have been thwarted by specialty societies that are enjoying the good times. If the reimbursement for post discharge care is low (which it is), then expect you will get a poor product for this low cost. Until all the time that is devoted to these essential communications is recognised and reimbursed, one can expect more of the same.
At the hospital where I admit, they have a fully integrated medical record, and this is indeed helpful to have access to when the patient returns back to my care, but what has happened is that this seems to serve as the de facto substitute for any verbal communication. Clearly there are some patients that require this direct one on one comminication due to the complexity of their medical predicament, but the only time I ever hear from a hopitalist is when they complain to their director that I have visited the patient in the hospital. Their concern is that I am billing for this service (I am not) thus negating their ability to bill for the same service.
The main work of primary care is coordination of care and communication between patients and other providers, but good luck trying to get paid for this time.
What I thought Family Medicine stood for
30 years ago was
Continuity.
Prenatal to
Wake
But I guess we need a
Script for Handoffs
Because my specialty
Is Dead.
We can’t hire residents
And pay them what we
Earn.
They won’t take it.
We have EMR, ER docs, OB
Priveleges, but make
Less than 100K.
Death Spiral for
Idealists
Realists
Generalists,
What about Care?
Why shouldn’t the
Family Doc
Bail on hospital
Care?
No one
Values his
Effort.
Maggie,
I’m interested in why you think that residents should work more ‘reasonable’ shifts?
Tom–
Why do I think residents should work more reasonable shifts?
Becuase when residents are sleep-deprived patients die.
On a traditional schedule, residents work 30 hours straight every other shift, and 10 hours straight on the “in between shift.”
As Harvard Medical School News points out: “After 10 hours on the job, a truck driver must pull off the road. After 16 hours, an airline pilot can no longer legally fly a plane. But after 24 hours or more on the job, with perhaps an hour nap somewhere along the line, a first-year medical resident can perform a surgical procedure, write a prescription, or insert a chest tube.”
This is scary.
On the traditional schedule, shifts often last longer than 30 hours: ” In practice, shifts tended to carry beyond their allotted time; nearly all interns worked 80 or more hours per week.”
On revised, more reasonable schedules, they work no longer than 16 hours at a time, for a total of around 65 hours per week.
When researchers (working in eight-hour shifts) shadowed the residents and compared compared errors under the two systems they found that residents made “35.9 percent more medical errors considered serious during the traditional schedule, including 20.8 percent more medication errors and more than five times as many serious diagnostic errors. ”
16 hour shifts mean more hand-offs–which can also lead to errors. But you can train physicians to reduce errors during the hand-off (as desccribed in post). You can’t train people not to make errors when they are seriously sleep-deprived;
Keith– I am afraid you are right that even patients fail to appreciate the importance of “thinking medicine” –the doctors who listen to you, talk to you, diagnose you, c-ordinate your care.
Americans have been trained to think that what some call “Sputnik medicine” (cutting-edge, hi-tech) is what saves lives. Certainly, it’s more dramatic. But what would really save lives (and healthcare dollars) in this country is much better chronic disease management.
That requires establishing a relationship with the patient (who has to help in managing the disease) and it takes place over a long period of time.
But I am hopeful that in a new administration Medicare will revist how it pays physicians, and begin paying more for co-ordination, primary care and mental health care, while paying less for some of the most expensive procedure which, everyone agrees, are overdone–in part because the payment system creatives incentives to do too many.
Here, for example I’m thinking of angioplasties and bypasses. Nearly every heart specialist I have ever talked to agrees that we do way too many. (No one ever says “I” do too many, but there’s a consensus that someone out there is doing too many.)
And we also know that we have too many cardiac centers in many places: when a new one is built, sudddenly the number of heart procedures done in a given town shoots up. Does this mean an increase in heart disease? No. I’ts suppply creating demand.
Keith, I also agree that we have to be careful that we don’t think that electronic medical records can or should substitute for all verbal communication among doctors, especially in complicated cases . ..
Great blog, I’m glad I found it! keep up the good work.
dr. david–thanks for the kind words, we hope you stay a while.
All, great comments as always–and the elephant in the room, as everyone points out, really is the payment system.
I second much of what Maggie says in her last comment. We systemically focus on doing the newest, coolest thing, without spending nearly as much time, attention, or money in trying to perfect the coordination and application of everything we already have!
To further complicate this communication or lack thereof mess, look at this disturbing article in Health Affairs:
Study: Physician-Owned Ambulatory Surgical Centers Siphon Off High-Paying Patients
Physicians who refer the most patients to physician-owned ambulatory surgical centers disproportionately send privately insured patients to these ASCs while sending Medicaid enrollees to hospital outpatient departments, according to a new study of referral patterns in the Pittsburgh and Philadelphia metropolitan areas, published today as a Health Affairs Web Exclusive.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.3.w165
NG–It’s really a separate issue, I suppose, but are you surprised? I’m certainly not. The private day-hospital/surgi-center that just opened in my small city may well sink the non-profit hospital across the street that has served the town for years.
Everyone wants everything.
No long shifts, no hand-offs, no mistakes, no over-spending, no missed diagnoses.
Every way of organizing these medical activities has a risk and a benefit. The same day I read this, I read a note elsewhere saying nurses and doctors were overworked and understaffed.
I’m not to the level of having my own ideas about hand-offs yet, but it’s nothing more than a reaction against the 120-hr weeks and unending call of the previous generation.
aaron,
I respectfully disagree with “hands-off” being a reaction to previous in humane training schedule. take a look at the business/profit of it. Can you think of another industry that has 24 hour coverage that doesn’t have second and third shifts? security, police, fire, nurses, and this is because doctors cost way too much to hire three doctors to cover 24 hours, not becuase it is otherwise a good idea.
drmatt, do you mean that it is more profitable to have people work through? I suppose, there is definitely the profit motive in having coverage provided by salaried house staff instead of shift-work MDs.
Wouldn’t handoffs (might as well clear up the grammar and make it one word) then be a disincentive to profit if hospitals were making more money with longer work schedules?
I guess I didn’t totally understand your point. Perhaps I’m just dense.
My practice is limited to consultative ultrasound in Ob-Gyn. We get referrals from many OB’s, PA’s, midwives, and FP’s in our area. On the referral slip, there is ample space to write a summary of pertinent clinical info which prompted the referral. Unfortunately for the patient, it is the rare referral which has any clinical info. We’re lucky the requested test is checked off. In fact, some patients arrive with blank slips – not even the name is on the slip. Consultation is a two-way street.
There are many primary care docs out there that don’t want to be interrupted by the ER doc or the hospitalist with an update or a phone call because they are either sleeping (middle of the night), or they are too busy in clinic to stop what they are doing to come talk to their fellow colleague.