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.
