Now that our entire enterprise is moving to a unified electronic medical record, we’ve seen enormous advantages appear across the spectrum of care. Being able to see everybody’s notes, and everybody’s labs and plans, has improved communication and collaboration significantly.
Many years ago, after a patient who was transferred from our practice to the emergency department suffered a catastrophic outcome due to poor and missed communication, we in the outpatient world, along with our colleagues in the emergency department, worked together to streamline and build a better process for all involved.
We created a dedicated telephone line where outpatient providers sending a patient over for evaluation could speak to the administrative attending covering the emergency department, to let them know what was up.
“I saw Mr. John Doe today in clinic, and he’s been having some fevers and abdominal pain, he has some pretty significant right upper quadrant tenderness with mild voluntary guarding, and I’m worried about cholecystitis or diverticulitis; he’s a bit tachycardic and his blood pressure is on the low side for him, and we can’t arrange an outpatient CT scan before the end of the day. I’m worried he may need to be admitted so I’m sending him your way.” The emergency department attending would then put them in their tracking system — “up on the board” — and we would arrange for him to be transported over to the ED for them to continue his care.
We also created a standardized printed form to send along with a copy of our office note that included the nuts and bolts of what we had found, what we were thinking, and what we were hoping to accomplish with the emergency department evaluation. This direct communication, along with very clear and specific instructions, was well thought out and created a system which we all hoped would prevent the “Swiss cheese” model of errors from occurring.
Now that we and our inpatient colleagues are all on the same system, writing our notes in the same places, we have dramatically improved this process even further with an actual order set for ambulatory transfer to the emergency department. It’s called “Ambulatory Referral to ED (aka Emergency Room)”. This includes all of the same things that we had in our previous form right in the electronic health record, allowing us to quickly and clearly communicate to those receiving our patient in the emergency department what we found, what we thought was going on, and what we expected and hoped that they would continue to do to further the patient’s care.
Many of us old-fashioned folks who have been doing this a long time still prefer the human-to-human contact, and are still placing a call to the Emergency Department to do that warm handoff so we can let someone know what’s coming their way, and they can hear the concern in our voices. Some folks in the Emergency Department have said, “You don’t need to call me; the order in the electronic health record is enough,” but it’s still a hard habit to break.
Now, I hope, it’s time to fix the process going in the other direction. When one of our patients is discharged from the hospital, there seem to be lots of different discharge summaries, discharge notes, hospital course descriptions in multiple different places, and massive collections of check-box items that those discharging the patient need to complete. What seems to be missing, and something that I hope we can improve upon, is a single comprehensive summary, and a very clear place for communicating what they found, what they did, what they think was happening, what worked and what didn’t, what they think should happen next, and what they want us out here in the outpatient world to take care of.
Disposition summary comments like “follow-up with outpatient PCP to discuss all results from ED visit” are not all that helpful. Were some tests pending at the time of discharge and needed to be followed up? Had the emergency department provider suggested some additional tests but the patient wanted to defer these until later? Does one of these blood tests done in the emergency department need to be repeated, or did they give the patient some medicine that needs follow-up monitoring or lab testing?
I know we can read through all the copious notes to find this information buried in there, but it would be much nicer if it was all bundled together in a nice discharge summary package, so that I knew what I needed to do to help continue this patient’s care. Comments like “Your care in the emergency department will not be complete until you’ve seen your primary care doctor for follow-up within 2 to 3 days” are not that helpful, unless I know exactly why they need to be seen so soon.
After an emergency department visit, most of my patients just want to rest at home and take the medicines that they were prescribed there for the problem I sent them in for in the first place. No sense making them come all the way back to my office 2 to 3 days after a laparoscopic cholecystectomy, if we can check on them through a video visit or telehealth, or we can get home labs drawn to allow them to continue to recover at home. Perhaps what we need is an “Emergency Department Referral to Primary Care” order to bring this all together?
Hopefully we can continue to collaborate on building better systems that remove all the excess fluff from around the edges — endless documentation that does very little to further a patient’s care — and create a better document for clearly communicating what went on, and what needs to happen next.
Better for all of those involved.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.
Last Updated May 03, 2021