One of the great strengths of our healthcare system is its specialization.
It is also one of its great weaknesses.
Here’s why: since there is such a proliferation of ‘-ists” (neurologists, cardiologists, pulmonologists) a primary care doc (particularly in urban settings) feel obligated to send the patient to the local specialist every time he encounters an issue beyond the scope of his expertise or practice.
Traditionally, the PCP (primary care provider) writes a referral, hands it to the patient on a piece a paper and….moves on to the next patient. In many instances, there is no tracking of whether the patient completed the referral and what happened if the patient did go.
Why is this a problem? Well, in the old model of visit based medicine—it really wasn’t a problem. The system was (and still is) based on individual encounters between various providers. Since the primary care provider (the main source of referrals) has no specific financial incentive to coordinate with others (other than professional courtesy), American healthcare does not have a well developed model for tracking the transition of patients from provider to provider (the buzzword for this process is called care coordination).
However, in the new world of accountability--as exemplified by accountable care organizations (ACO) and patient centered medical homes (PCMH), primary care practices are supposed to know if you showed up for the cardiology referral and what happened when you went there.
In this new model, patients will have a “home” (a primary care practice) that is responsible for helping patients navigate the system if they are referred out and working with patients and specialists to make sure that referral appointments are kept (or at least understand why they are being neglected). Moreover, the primary care practice will be expected to consolidate the reports from consultants so that they have global view of their patients.
The clinical and financial reasons for this are sound; patients that neglect completing their referrals may be compromising their health. Compromised health can lead to expensive interventions (like emergency ED visits or inpatient admissions) that might be avoided with better coordinated care.
This new and long overdue focus on care coordination exposes one of the fundamental weaknesses of our system; we do not have a good way of electronically communicating information between practices. Yes, there is secure email, but it is not universally distributed and used and has no real work flow component. The Continuity of Care (CCD) is great start for creating a standard for distributing clinical summaries, but will not be enough for managing the subtleties of care coordination.
There seems to be the misguided notion that somehow the EHR will fill this void, but that is pipe dream; at its heart an EHR is internal documentation tool—not a means for communicating between practices. Some wags think the HIE (health information exchange) will provide the infrastructure. I wouldn’t bet on it—an HIE is too complex and expensive and was not intended as a workflow tool.
In the absence of software based communication methods, practices use people, fax, and telephone. This is going to change—and the cloud is going to be enabling technology. The cloud allows the development of light, subscription based, work-flow enabled applications that can be rapidly and inexpensively deployed. It is no longer necessary to build a behemoth IT infrastructure in order to get things done. We already have an infrastructure; it’s called the internet.
Insightful companies are starting to pickup on this. Clarity Health Services in Seattle is offering a web-based care coordination platform that is starting to create some noise. Athena Health recently acquired a cloud based care coordination company (Proxsys) to complement its EHR and billing service offerings. There will be more.
What questions do you have?
Bruce Kleaveland is President of Kleaveland Consulting and a sponsored health IT correspondent for Intel.