Emergency, Primary Care Physicians Need More Teamwork

February 25, 2011

February 25, 2011 — Emergency department (ED) physicians and their primary care counterparts all too often work poorly together, and that spells trouble for patient care, say researchers at the Center for Studying Health System Change (HSC) in a new study.

In one common example of clinical uncoordination, a primary care physician (PCP) refers a patient to a hospital ED but fails to send along pertinent chart information. Or the material gets lost in transit. As a result, the patient arrives in the ED as a medical blank slate and announces to a physician, "My doctor told me to come over here," according to the study, conducted for the nonprofit National Institute for Health Care Reform.

Operating in the dark, an ED physician may duplicate tests and procedures already performed by a PCP.

But when PCPs brief ED physicians about why they are referring a patient, patient care can become more streamlined. "It probably gets you to manage the patient a little quicker," one ED physician told researchers.

The researchers write that better communication and coordination among PCPs and ED physicians are more important than ever since the nation’s new healthcare reform law will extend insurance coverage to more than 30 million additional Americans, who will be more likely to visit EDs as a result.

Barriers Are Personal, Technological, Financial

The HSC team last year interviewed 21 pairs of ED physicians and PCPs who practiced at the same hospital in 12 communities across the country. They uncovered numerous hindrances to teamwork, some of them reflective of structural changes in medicine.

With more hospitalists on the job, fewer and fewer PCPs round at the hospital; consequently, PCPs miss the opportunity to develop close working ties with ED physicians. At the same time, the shift to group practice means that ED physicians who seek information about a patient from his or her regular doctor may end up talking to a less knowledgeable cross-covering physician instead.

Other barriers to teamwork are technological in nature. Telephones trigger time-consuming phone-tag. Faxing records does not permit real-time dialogue, nor is it readily apparent that faxes arrive at their destination or get read. That uncertainty also characterizes email, although this medium at least enables an online conversation. ED physicians and PCPs may use electronic health record (EHR) systems that cannot talk to each other.

Then there is money. Discussions about follow-up care for a patient leaving the ED go unreimbursed and distract both ED physicians and PCPs from the crunch of patients and billable services in their respective workplaces, the HSC researchers write.

The authors recommend wide-ranging solutions to the problem of poor coordination of ED patients. Communitywide networks of interoperable EHRs among providers would allow an ED physician to easily view medical records maintained by a PCP. Federal incentives for meaningful use of EHRs could be revised to reward that kind of data sharing. And rewarding conglomerations of physicians and hospitals for controlling the utilization of services — and therefore costs — will motivate ED physicians and PCPs to work in tandem.

More cooperation also depends on medical liability reform. Right now, ED physicians tend to be the only ones sued for malpractice when they decide not to conduct a certain test or admit a patient because a PCP told them it was unnecessary — and then something goes wrong. This unequal risk discourages ED physicians from soliciting advice from PCPs in the first place. The HSC researchers recommend that states revise their medical liability laws to give EDs a "safe harbor" from malpractice claims if they coordinate patient care with their PCP colleagues.