Poor communication and disparities in information-sharing strategies are hampering the coordination of care between hospital clinicians and primary-care physicians (PCPs), according to a new study conducted by the School of Medicine of the University of Colorado Anschutz Medical Campus (CU Anschutz). That can potentially lead to an increase in missed test results and hospital readmissions.

DOTmed News had the opportunity to speak with Dr. Christine D. Jones, the study’s corresponding author, assistant professor of medicine and director of the Hospital Medicine Group of the Care Transitions Program, about this issue and what hospitals and practices can do to solve it.

DOTmed News: What problems arise as a result of poor communication and gaps in information strategies between hospital clinicians and PCPs?

Dr. Christine D. Jones: Multiple problems can arise from poor communication between hospital and primary care clinicians. One example would be when test results are pending at the time of a patient’s discharge.

The hospital clinician may have documented the need for the primary care clinician to follow up this test in their discharge documentation, yet if discharge documentation is not received by the patient’s primary care physician, it is possible that neither clinician is following up on this test result. One can imagine how this could lead to patient harm if, for example, the test is a biopsy to evaluate for cancer.

Another problem that multiple clinicians described resulted from not having clearly defined roles for hospital clinicians and primary care clinicians when patients are receiving skilled home health care services.

Home health care services are ordered for patients who need additional support following discharge to aid in their recovery, such as therapy or intravenous antibiotics. For example, a home health care nurse requires physician orders to remove a long-term central intravenous line for a patient who has completed a course of home intravenous antibiotics.

The hospital clinician assumes that the primary care clinician is managing the patient, but the primary care clinician either is not aware the patient was in the hospital or hasn’t seen the patient yet after the hospitalization so the PCP is unable to write home health care orders.

This can be problematic for the patient, because the longer a central line is in place, the more of a chance it has to cause infections or blood clots.

DOTmed News: In a perfect world, how would hospital clinicians and PCPs communicate?

CDJ: Clinicians had different ideas when it came to their ideal state of communication. Certainly, having shared access to electronic medical records was described as helpful, but did not solve all communication problems.

For uncomplicated hospitalizations, most clinicians agreed that exchanging discharge documentation was sufficient. However, for more complex patients, primary care providers and hospitalists described that having access to two-way communication with clinicians in the other setting would be helpful.

Such two-way communication could help when complex decisions are being made that require PCP management in the outpatient setting, for example, starting a patient on a blood thinner, or managing treatment plans for patients with frequent hospitalizations.

DOTmed News: What can hospitals and practices do to improve that communication?

CDJ: Some examples that I have seen to improve communication have included hospitals and primary care practices engaging in discussions to ensure that primary care practices are receiving needed information about hospitalizations, either by fax or through the provision of web-based access to the hospital’s electronic medical record. Such engagement between settings also ensures that practices are responsive to hospital needs for expedited follow up appointments for complex patients.

A few hospitals and primary care practices described success with having a “point person,” often a case manager or a social worker, who is responsible for ensuring a smooth transition both into and out of the hospital by coordinating with practices in the other setting.

The most successful communication was often between clinicians in different settings who had pre-existing relationships, and as a result, already had access to cell phone numbers and emails for each other.

Clinicians in focus groups brought up the idea of having frequent meetings with their counterparts in the other practice setting to improve relationships and communication.

DOTmed News: Do you think that government regulation should play a role in improving this?

CDJ: Clinicians spend much of their time seeing patients face-to-face and documenting these encounters without extra time allotted for the extra, non-face-to-face activities that might ensure patients have a smooth discharge to the outpatient setting.

Recently, Medicare has become more supportive of efforts to coordinate care between settings to promote safe transitions of care for patients.

One key example of this is that in January of 2015, Medicare started to reimburse clinicians for non-face-to-face care coordination for patients with multiple chronic conditions at risk of decompensation.

Although this doesn’t directly address one of the primary reasons that clinicians cited for not coordinating care to their best ability, which was was not having time to do so, it does at least offer clinicians reimbursement for their time dedicated to non-face-to-face care coordination.