Hospital and emergency room utilization is expected to increase substantially when 35-40 million Americans become newly insured through Medicaid and State Health Exchanges starting in 2014.  Today, communication between primary care physicians and hospital emergency departments is poor.  An excellent new study by the National Institute for Health Care Reform (NIHCR) examines how primary care physicians (PCPs) communicate with hospital emergency departments (EDs) and describes ways to improve communication:

The Changing Model of Communication Between Primary Care Physicians and Hospital Emergency Departments:

Coordination of care can take place in several ways.  The patient can provide information to physicians, EDs can consult with PCPs (or their office), and EDs can access patient information in electronic health records (EHRs).  Research shows that when direct communication takes place between PCPs and EDs, it is almost by telephone.  PCPs often fax documents to EDs regarding a patient’s medical history.  Electronic communication (email, text messaging), which is often more reliable, timely, and easier to read, is rarely used.

Prior to the increased use of hospitalists, PCPs would often admit patients and oversee their care.  This forced the PCPs to at least have a physical presence in the hospital, providing EDs with more opportunities for direct communication with patients’ regular physicians.

Today, physicians involved in primary care and emergency care often complain about poor, inefficient communications.

Opportunities for Communication:

  1. Initial Assessment: While some physicians communicate with EDs via telephone or the sharing of documents, greater and more frequent communication as to the reason for a patient’s referral would streamline the care process.
  2. Formulation of Care Plan: Researchers found that ED physicians rarely communicate with PCPs before developing their care plans.  When an electronic health record (EHR) is available, EDs are even less likely to contact PCPs.  However, both PCPs and EDs agree that greater communication in the planning stages would be beneficial, especially for patients with chronic conditions and complex medical histories.
  3. Disposition: Increasing communication as patients are released from hospitals will give PCP’s greater information as to what has been done and may need to be done in the future.  Most ED physicians and PCPs agree that this communication is valuable for follow up planning and ensuring a safe hospital discharge.  Yet PCPs also note that discussing details of their patients with EDs, especially those that sought hospitalization with non-emergent complaints, may not be the best use of valuable time.

Barriers to Communication:

Real Time Communication (telephone): Since most communication is done via telephone, PCPs and EDs often find it difficult and frustrating to connect with one another as they are each busy with their respective roles.  EDs may have to wait several hours for PCPs to locate files and discuss an individual patient, and calls often go unanswered as physicians may be busy with other individuals.

Asynchronous Communication (fax, text message, email); These messages offer greater flexibility but limit the ability of EDs and PCPs to have an efficient “back and forth” conversation.  Also, unless a response is sent, the sender will not know that the receiving physician has received and is utilizing the information.

Shared Electronic Health Records: Using EMRs may streamline physician to physician contact, but many note that EHRs don’t always contain complete histories of a patients care or lab results.  For example, if a portion of a patients care is obtained outside of an integrated care system, it may not be recorded in the EHR.

Lack of Time and Reimbursement: Multiple brief telephone calls per patient can eat up significant portion of a physician’s time.

Limited Rrole of Cross-Covering Providers: EDs and emergency physicians are less likely to speak to a physician that has information and suggestions to share about a given patient.

Changing Interpersonal Relationships: With fewer opportunities for interaction and collaboration, physicians may not know what services their counterparts are able to provide.

Risk and Mmalpractice Liability Concerns: While PCPs may have more interaction with patients and a greater ability to learn about a given patient patients, ED physicians do not.  Physicians in the ED may be more reserved and cautions due to liability concerns.

Policy Implications:

Given all this, it may seem the answer is to create incentives so physicians are reimbursed for their time communicating with other physicians about a patient’s care.  However, this may not be a viable solution because:

  1. Communication is difficult to measure.
  2. Communication takes time that may conflict with other priorities with their own incentives, such as length of stay.
  3. Coordination must be fit into the complex workflows of EDs and PCPs offices.

There are several ways in which policy could improve communication between primary care physicians and hospital emergency rooms.

First, as EHRs are developed and improved, continuously improving “meaningful use” criteria and promoting wide, complete use of EHR systems by all physicians and hospitals should result in far better communication.

Second, physician communication can be improved through payment reforms.  The changing model of how physicians are paid and employed is already improving communication.  For example, as individual practices are being absorbed into larger hospitals and health system organizations, communication becomes more feasible and likely.  Or, payment rates may be bundled to facilitate communication, as opposed to considering emergency care a separately reimbursed item.

Lastly, malpractice reform may be used to facilitate more communication.  Currently, PCPs are exposed to the least risk yet often have the greatest background knowledge of a patient. ED physicians are exposed to greater liability with having little or no knowledge of the patient’s background.  PCPs might know of alternatives to a hospital stay, but without effective communication this information is not relayed.  As a result, emergency room physicians are more likely to recommend hospitalization in order to decrease their own liability.

Learn More:

The study – Coordination Between Emergency and Primary Care Physicians – was authored by Emily Carrier, MD, MSCI and Tracy Yee, PhD, both with the Center for Studying Health System Change, and Rachel A. Holzwart from Mathematica Policy Research.

To read the study, click here (PDF).

The National Institute for Health Care Reform is nonprofit, nonpartisan organization established by the UAW, Chrysler, Ford Motors, and General Motors. The Institute contracts with the Center for Studying Health System Change (HSC) to conduct health policy research and analyses to improve the organization, financing and delivery of health care in the United States. For more information about the National Institute for Health Care Reform, visit www.nihcr.org.