Hospitalist Edward Ma, ACP Member, has tried to get his colleagues to work more closely with primary care physicians (PCPs).
“The PCPs constantly complained that our hospitalist group was not communicating with them. No matter what some of us urged internally, we could not effect change,” Dr. Ma, who now practices at The Chester County Hospital in West Chester, Pa., said about a group where he worked previously.
A number of factors may contribute to some hospitalists' failure to communicate, including high turnover of hospitalists and lack of competition. While those barriers may be hard to change, closer relationships between primary care physicians and hospitalists and resulting improvements in patient care are achievable with relatively little effort, according to Dr. Ma and other physicians working on this issue.
“If the hospitalists are not communicating as the PCP would like, then I suggest the PCP take some of the initiative to open the communication channels and establish relationships with the hospitalists. This might change the attitude of the hospitalists,” said Dr. Ma. “Both sides, the PCPs and hospitalists, are busy and neither may really know what the other side would want or what they need.”
When and how
Primary care physicians can begin to remedy this problem by conveying their wants and needs to local hospitalists. “Some docs want a lot of communication. Some want none unless it's absolutely necessary,” said Dr. Ma. “Do you want to be called on every admission? Every discharge? Or do you want to only be called on the complex matters?”
These questions should be answered when an outpatient practice and a hospitalist group first create a referral relationship, experts said. That's also a good time to discuss the preferred means of communication.
“A methodology that works for both [the PCP and the hospitalist] has to be worked out,” said Len Scarpinato, FACP, chief medical officer for Cogent Healthcare's north-central region. “In some markets, we've evolved to dropping information on a voice mail. In other markets, it's been ‘Go ahead and page me. I want to hear about my hospital patients.’ In other markets, it's ‘Call my nurse. She'll listen and tell me in between patients and I'll call you back if I think I need to talk to you.’”
In some instances, the best method of communication may not involve a phone at all. “I think e-mail is a wonderful medium for sharing patient information as long as it's done carefully,” said Daniel J. Brotman, FACP, director of the hospitalist program at Johns Hopkins Hospital in Baltimore.
Dr. Brotman recently led the development of a call center that allows community physicians to contact a hospitalist and admit their patients to Johns Hopkins without going through the emergency department, but he's previously run into problems communicating with primary care physicians on the phone. “Sometimes we end up on hold dealing with the same sort of systems that patients have to contend with when they call to make an appointment,” he said.
Phone calls aren't always convenient for primary care physicians either, as one hospitalist group, which had routinely called primary care practices when patients were discharged, found.
They polled their referring physicians about how they'd like to be contacted. “We were surprised how many of them said, ‘Send me an e-mail.’ When the patient comes in a week later, they don't have to recall the phone call,” said Morgan Moncada, MD, medical director for Inpatient Management, Inc. at Reid Hospital in Indiana.
The fax also remains a popular method of communication. “There was a group of doctors who said, ‘You don't have to bother calling or anything.’ We still fax them everything,” Dr. Moncada said.
Outpatient internists may want to specify that “everything” should include not only the discharge summary, but also the information that the patient has received, according to Lisa B. Johnson, ACP Member, a general internist in West Chester, Pa.
“I really like getting the exact discharge sheet faxed to us that the patient's been given, because then you know exactly what the patient should know. So when the patient starts describing what was written or how the hospitalist changed a dose, you know exactly what was done,” she said.
At some hospitals, those faxes can be sent automatically. “We're optimizing some of the automated methods, such as autofaxing admission history and physicals and autofaxing not only the discharge summary but also the discharge worksheet to referring providers,” said Dr. Brotman.
But even with automation, there's still going to be a need for doctor-to-doctor communication, the physicians said.
“Commonly, we would also get a call saying, ‘This is outstanding, or this is what we did. The patient is going to come and see you in so many days and this is what you should follow up,’ which was very helpful,” said Antonette Brigidi Frasch, ACP Member, assistant professor of medicine in the division of general internal medicine at the University of Pennsylvania in Philadelphia, who was previously in outpatient practice affiliated with the Chester County Hospital.
Primary care physicians can also take the initiative in these contacts. “Just put a phone call in and say, ‘Hey, keep me apprised of what's going on with the patient,’” suggested Dr. Ma.
The advent of electronic medical records (EMRs) may reduce the need for direct communications. “We just got electronic medical records and the hospital has them and I think we're weeks to a couple of months away from having a link. Right now, we just have a sign-in number for the Internet,” said Dr. Johnson.
Linked EMRs can facilitate information transfer in the opposite direction as well, noted Dr. Scarpinato. “In many markets, we'll get a read-only privilege of that doctor's EMR. In those places where the PCP is still on paper, which is a fair amount of the PCPs and their offices, we'll ask them to fax over pertinent progress notes and/or studies that they've done,” he said.
Give without being asked
In addition to allowing access to records, outpatient doctors can smooth transitions by offering useful information to hospitalists caring for their patients. “It helps if you help them, if you know you're sending a patient who is not a very good historian or if you're sending someone just to a procedure unit for a transfusion. If you have information to give the hospitalists so you can keep it as painless as possible for them, then they tend to do the same thing back,” said Dr. Johnson.
“If I was sending a patient from the office, I would call and let [the hospitalist] know,” agreed Dr. Frasch. “It's reassuring the patient that we would be communicating [and] also so [the hospitalists] are clear on what our question was, what the status of the patient was when we saw them, any tests we've done.”
Providing prior test results can be a major help to hospitalists and patients, who may then avoid unneeded testing. “You are admitting somebody and you're thinking, ‘I'm concerned about this patient's chest pain. Maybe I should be getting a stress test or a cardiac cath,’” said Dr. Brotman. “You can be far more confident in not ordering additional diagnostics if you know it's a tree that has already been barked up.”
If the patient is likely to need consultation by a specialist, any preferences about which doctor to call are worth mentioning, too. “It's especially helpful for the hospitalist to know what specialist I may have a relationship with because it's just a brief time they'll be in the hospital, but then that specialist is typically who they continue with after discharge,” Dr. Frasch said.
The patient is also likely to return for a primary care visit soon after discharge, and that's another point where a close primary care physician/hospitalist relationship can be beneficial. “The patients will tell you about the hospitalist and you can say, ‘Yeah, he's quiet, but it doesn't mean he doesn't care.’ It makes your patients feel better when you talk about the hospitalists as if you do know them and contact them,” said Dr. Johnson.
That conversation may also affect any future visits that the patient makes to the hospital. “If [primary care physicians] can relay confidence in the people taking care of the patient during the hospital stay to that patient, then the patient is going to have a better experience in the hospital,” said David DeSantis, MD, a hospitalist at Reid Hospital.
Building a relationship
To help give outpatient physicians that confidence, some hospitalist programs have undertaken efforts to get to know their referring physicians.
In Dr. Moncada's practice, the nurse director, alone or with a hospitalist, makes quarterly service calls to referring practices. “We bring them lunch and we really kind of pattern ourselves after the pharmaceutical marketing call. We go out to the offices and ask them about how did they like our service, has anything changed for them—basically getting an idea of what works and what doesn't work with these offices,” Dr. Moncada said.
The program makes an effort to assign these visits to hospitalists who already know the community physicians, whether from church, kids in the same school or some other personal connection. “We capitalize on those previously established relationships,” said Dr. Moncada.
In Cogent's hospitalist groups, the program manager and medical director typically meet in person with primary care physicians at the start of their referral relationship. They maintain communication through surveys of primary care physician satisfaction and return visits to the practices. “[The hospitalist leaders] say, ‘We're here. Can you take five minutes to tell us how things are going?’” explained Dr. Scarpinato.
In instances where the feedback is negative, the program leaders take responsibility for fixing the problem. “Occasionally there's one that will say, ‘I didn't like what you did with my patient. You used too many new medications. You didn't inform me.’ That's the job of the program manager and the medical director to reach back into the chart, figure out which hospitalist did that and do some quality control so the primary care physician is happy,” said Dr. Scarpinato.
Happy, communicating outpatient physicians and hospitalists should then be better equipped to accomplish their shared primary goal. “We're both trying to do what's best for the patient and the only way that happens is if we're constantly communicating,” Dr. Scarpinato concluded.