21st Century Medicine Fraught With Miscommunication and Human Error

By Niko Karvounis, Health Beat. Posted March 20, 2008.

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 healthcare 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 healthcare necessitates a "pluralistic delivery system that features large numbers of small providers, [which] magnif[ies] the number of venues such patients need to visit." Twenty-first century medicine is too complex for one-stop shopping.

Inescapable though it may be, the hand-off is wrought 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 rework, 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).

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Niko Karvounis is a program officer with the Century Foundation in New York City, where he works on issues of socioeconomic inequality and healthcare. He is a regular contributor to Health Beat, the foundation’s healthcare blog.

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