Little attention has been paid to care coordination for patients treated in hospital emergency departments (EDs), according to the study. As more people become insured under health reform coverage expansions, ED use likely will increase, along with the importance of better coordination between emergency and primary care physicians to avoid duplicative and misapplied treatment.
“There are no easy answers to the coordination issues between emergency and primary care physicians. Policy makers will need to examine a broad range of ways to address the problem—pieces of the puzzle include payment reforms, standards for health information technology and malpractice liability reform,” said HSC Senior Researcher Emily Carrier, M.D., M.S.C.I., coauthor of the study with Tracy Yee, Ph.D., HSC researcher; and Rachel A. Holzwart, a survey associate at Mathematica Policy Research.
The study’s findings are detailed in a new NIHCR Research Brief —Coordination Between Emergency and Primary Care Physicians. Researchers conducted 42 telephone interviews between April and October 2010 with 21 pairs of emergency department and primary care physicians. Emergency department and primary care physicians were case-matched to hospitals so the perspective of both specialties working with the same hospital could be represented. Other key findings include:
• Real-time communication:While alternative methods could be useful in many cases, real-time, physician-to-physician communication was essential in some circumstances, according to respondents. However, they agreed that communicating via telephone was particularly time-consuming. Both emergency and primary care physicians reported successful completion of each telephone call often required multiple pages and lengthy waits for callbacks.
• Asynchronous communication:Asynchronous modes of communication, such as faxes, did not require breaks in task but had significant limitations as well. Faxed records can be reviewed at providers’ convenience but do not provide an opportunity to converse in real time and ask questions. Physicians had little confidence that faxes were carefully reviewed by their intended recipient and often reported that faxed records were poorly organized and difficult to decipher. “What used to be a few pages is now 20-30 pages” of ED record, one PCP said.
• Shared electronic medical records.Sharing information through a fully interoperable electronic medical record can address some barriers. In this model, emergency physicians could read patients’ medical record to learn their history and could alert primary care physicians about their patients’ ED visits by flagging a note for review or triggering an e-mail directing them to review the record. These approaches could be supplemented with telephone calls as needed, although emergency physicians with access to these systems reported less need to call primary care physicians. However, while electronic medical records are valuable tools for billing and liability documentation, they are not yet designed to offer a rapid overview of a patient’s case that is relevant to a particular problem with the level of detail that could help an emergency provider direct care.
• Lack of time and reimbursement. Emergency and primary care physicians most commonly cited insufficient time and lack of reimbursement as significant barriers to communication. While the activities of care coordination—for example, placing and receiving telephone calls—might seem straightforward and quick, providers noted that each small action multiplied across dozens of patients can become a daunting burden, with little immediate reward.
Limited role of cross-covering providers.Another overarching barrier to effective coordination is the role of cross-covering providers. The rise of larger groups and more elaborate cross-coverage systems means that emergency physicians are less likely to speak with a physician who has direct knowledge of the patient. Respondents agreed that time invested in care coordination through a cross-covering primary care physician yielded much less value because cross-covering physicians rarely knew the patient and were less likely to offer information or suggestions that would change an emergency physician’s plan of care.
• Changing interpersonal relationships.While rising hospitalist use and the growth of larger primary care groups help PCPs decrease their call responsibilities and maintain a more balanced lifestyle, they inevitably decrease interactions between office-based and hospital-based physicians. Many emergency physicians reported that they had no venues for ongoing collaboration with primary care practices in their community.
• Risk and malpractice liability concerns.Even if practical barriers to communication and coordination are removed, liability concerns may keep providers from participating fully in care coordination. Many respondents noted that emergency and primary care physicians are bound by different constraints and have fundamentally different assumptions regarding patients’ reliability and resilience.