Opinion | Care Coordination and Other Opportunities for Improvement

Everybody wants something different. And everybody needs something different.

Every day, when we go to work, different things raise our hackles. We are working in a healthcare system that has so many moving parts — so many rules and regulations, so many people looking over our shoulders and telling us how we should run our practice and how we should take care of our patients. An idealized healthcare system would give us all the tools we need, build a seamless system that we and our patients can flow through, and make getting to the best state of health as effortless as possible, for them and for us.

Improving Care Coordination

Take coordination of care. A few weeks ago, a patient came to see me for “medical clearance” for a minor outpatient procedure, something that would be done in the surgeon’s office with little or no risk to the patient. They brought in a form from the surgery practice which asked me to recapitulate their entire past medical history, medical record, and physical examination on that day onto a piece of paper.

So in addition to inputting my office note from that day into the patient’s electronic health record, I was being asked to copy everything — their past medical history, their past surgical history, their medications, their allergies, their social history, their family history, their physical exam, their review of systems, and my medical assessment of their risk for undergoing this procedure — out onto a paper form. Especially irksome was the “history of present illness” where they asked me to write down the history of the issue that the surgeon was operating for, and copy over onto the form the long, complicated name of the operation itself, followed by a box I was asked to check that said, “Patient cleared for surgery.”

And this from a surgeon who, while they are not located right on our campus, is in our institution and uses the same electronic health record as me, and can see all of my notes, as I can see theirs. Every question that they’d asked was essentially already answered, except for my medical assessment as to whether any interventions needed to be done before this procedure for the patient’s safety — it was all right there in our shared EHR.

A Better Solution

During the office visit, I told the patient that I don’t hand-write information from my electronic medical record onto a paper form to then be faxed to another doctor’s office so they can scan it back into the very same EHR where that information already exists. What I am willing to do is electronically copy my note to the requesting surgeon when I close the office visit, and they get all the answers they need.

Unfortunately, as you can imagine, this led to no fewer than three phone calls and EHR messages from the surgeon’s office to mine, demanding the paper form. After I’d clearly explained to them the illogic and the risk of introducing new errors, coupled with the fact that they were unlikely to read my note either on paper or in the EHR, they finally said, “Hey, you’re probably right. What a neat solution!” This gets my hackles raised.

Everybody needs something different. Some are frustrated by the clumsiness of the EHR. Some are frustrated that with every upgrade to the EHR, they fix something we did not think was broken, and move something right when we’d finally figured out where to find it. Some are frustrated by the fact that we use so much paper, or that we have so many questionnaires that patients need to fill out. Some are frustrated by not having enough information that patients can fill out for us, to make the visit easier, such as their goals for the day and what refills they need.

Some are frustrated that our media section is endlessly clogged up with thousands of pages of administrative uselessness that obscures any relevant clinical information you may want to find there. Some are frustrated with the lack of support, too many people saying, “It’s not my job,” no one helping out with what our patients and what our practice really needs. Some are frustrated with phone messages that, despite multiple attempts to reiterate what needs to happen before the message gets sent to the provider, continue to contain things that make us need to do more work before we can get the patient the care they want.

How many times does a provider want to get an urgent message that says, “Patient called, requests a referral to a cardiologist, please enter ASAP.” What cardiologist? Why are they seeing them? Have they told me about this problem before? If so, perhaps I should try and evaluate it before they use (waste) a specialist’s precious time. And if it’s just a regularly scheduled 6-month follow-up with their cardiologist to manage their complex heart failure, why do I need to be involved in this referral process in the first place?

Using Our Creativity

A couple of years ago I instituted something at our practice I call “Lunch with Fred.” I’ve offered this to all of the faculty, the attendings, and the nurse practitioners. It’s an opportunity to go away from the office, out to lunch at a local restaurant, and complain to me. Tell me what they need, tell me what works and what doesn’t work, tell me the ideas they have about what we could do better. Help me find a way to work with what we’ve got, or point out something that’s worth demanding more resources for.

We all recognize that we’re functioning in a resource-constrained environment, that nobody’s just going to pay us more, that nobody’s just going to hire a bunch of physician assistants and more nurses and double our exam room space, just because we ask nicely — even if we present them with a business plan that makes them some money. But perhaps we can optimize what we have, start working on so many of the things that irk us as we go through the day, that make our lives and our patients’ lives so challenging.

I know that large practices, especially at academic medical centers, feel the need to standardize everything. They don’t want to deal with a whole bunch of ornery physicians who want to practice the way they want to practice and who have very particular tastes about how the patients are registered, what forms they get, and what services they are offered. But perhaps if we allow those of us with years of experience to use our creativity to develop some solutions, we’d all be better off.

I think it’s high time we built a model where everything gets offered up to everybody — every questionnaire, every opportunity to tell us about their health. Every patient gets all the education material, resources, and community health worker assistance they need; every patient gets a nurse, a social worker, and a nutritionist to be, while not fully at their disposal, available if they need them.

If we can engage the physicians, engage our patients, and give everybody a little more of what they need and what they want, we’re all probably going to end up being much better off. And isn’t that what we’re all really asking for?

That, and lunch with Fred.

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