21st Century Medicine Fraught With Miscommunication and Human Error
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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).
Making things worse is our fee-for-service system, which, as Dr. Kevin Pho (aka blogger KevinMD) notes, pressures "primary care physicians to squeeze in more patients per hour" and thus encourages a short attention spans vis-Ã -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 mixups 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 healtcare 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 not, 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 healthcare as a series of distinct, unrelated stages. Medical professionals should continue to rethink this model and realize, to paraphrase Kaiser's Michael Leonard, that healthcare 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.
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 foundationâ€™s healthcare blog.