There was a time in the not so distant past when physicians actually talked with one another. Typically, they would gather in a tight circle of white coats, arms folded, brows furrowed, discussing a complicated patient. From this huddle emerged a coordinated plan to solve the patient’s various problems. This was old-school coordination of care.
Fragmentation of Care
Those days are gone. Today, many physicians operate independent practices. They rarely if ever see their colleagues, let alone talk to them. With the advent of the hospitalist era, physicians rarely see their own patients in the hospital1.
Information transfer is also problematic. Even if the physician receives papers documenting things that happen to the patient outside the office, those records are often incomplete and sometimes difficult to read.
When a primary care physician refers a patient to a specialist, the patient often arrives without any sort of documentation, electronic or otherwise, explaining why the patient is there. Important details of medical history, medications, etc. are often missing.
After the specialist visit, the primary care physician often does not get a letter explaining what occurred during the consultation. It goes without saying that the consultant and the primary care physician rarely speak on the telephone.
Similarly, if a patient visits an emergency department or is admitted to a hospital, the primary care physician rarely knows about it.
Everyone suffers as a result of this fragmentation of care. First and foremost is the patient, who is subjected to unnecessarily repeated tests and overtreatment for self-limited conditions. They spend increasing amount of time away from their own homes, where surveys say they would prefer to recover from most illnesses2. The physician is not satisfied because the patient is not cared for properly. Finally, payers are not satisfied because fragmented care is very expensive.
There are several reasons for care fragmentation3. One is the limited use of EMRs by primary doctors. Another is a lack of a common electronic language that would permit EMRs to communicate. Finally, until recently, the payment system did not reward efforts to coordinate care.
Coordination of Care
True coordination of care has a few common characteristics. It is timely: patients receive referrals and access to consultants without needless delays. It is effective, meaning that the referrals and care transitions are based on best practices and scientific knowledge. Excellent coordinated care is efficient, meaning that referrals do not result in unnecessary duplication of tests and services that waste money and time. Finally, good coordinated care is patient-centered: the patient’s needs and preferences are paramount. Congress recognized the importance of all these elements when passing the IMPACT Act of 2014.
The Technological Solution
The solution to the fragmentation problem is technology. The components are all in place. The trick is to get all the pieces to fit together in an integrated whole.
The most urgent need is a solution to the “interoperability problem4.” Interoperability refers to the ability of EMRs to transfer and understand patient information. The problem is that the numerous available systems do not speak the same language. It’s a kind of Tower of Babel situation. The solution is for the several EMR vendors to meet in a summit and agree on industry standards. Similar summits in other industries such as telecommunications and banking gave the world a system that allows phone calls and texts to be exchanged world-wide and automatic teller machines that accept your card anywhere on the planet. The same type of achievement is possible in the healthcare world. All that is required is the will to get it done.
The most promising solution that technology offers healthcare is the ability to put the patient at the center of care. No one knows patients’ preferences and desires better than the patients themselves. Emerging technologies put control over healthcare decisions literally in the hands of the patients. It is in every player’s best interest, including providers and payers, to make sure that patient care remains coordinated, and that future fragmentation crises never occur again.
- On educating and being a physician in the hospitalist era | NIH
- Willingness to pay to assess patient preferences for therapy in a Canadian setting | BioMed Central
- Reducing Care Fragmentation | California HealthCare Foundation
- Interoperability: What it Means, Why it Matters | American Health Information Management Association