Over the past 10 years, as hospitalist programs have become the standard of care and as primary care clinicians have started practicing outside the hospital, specialists and referring primary doctors have interacted with one another less than they once did.
This loss of face-to-face interaction between inpatient and outpatient physicians affects care transition. A primary care doctor who knows the specialists in the system can make a more successful referral for a patient, not from just a quality standpoint, but from a relationship perspective. Patients want to feel like they are receiving a confident referral in their treatment and care.
Also, patients have choices. Patients may report back to their primary care physician that the specialist to whom they were referred had an unwelcoming front office or experienced difficulties scheduling an appointment. When there is a standing relationship between the two doctors, it is easier to share that type of feedback for improvement.
Fortunately, there are ways to close the gap: restructuring governance so physicians can meet, training them together and employing communication technology.
Health care organizations can improve communication between inpatient and outpatient physicians when the governance structure is designed to include both. Governance structures are often developed to focus on practice areas that are highly serviced, so there tends to be more representation among outpatient practitioners. Incorporating hospital-based physicians in the governance structure will ensure voices from both camps are heard.
Brian Lipman, M.D., chief physician operations officer of ProHealth Care in Wisconsin, realized that striking the right balance between the voices of primary care physicians and specialists, as well as improving communication between the groups, could improve the patient experience.
“When I came into the group there were very few specialists involved in our governance structure,” Lipman said.
Lipman created several operational committees, one being the physician advisory group. This group, which used to comprise just the chairs of ProHealth's 15 clinics, was expanded to include the chairs of the medical subspecialties.
“When I came into this role, the medical director of the hospitalist program was never invited to this type of meeting,” Lipman said. “They touch half the patients that are admitted to the hospital. Why wouldn’t they be invited?”
Though the focus of the physician advisory group is to review operational changes in the clinical and ambulatory environments, at each monthly meeting a hospital-based physician, either independent or an employee, is asked to give a short presentation on a recent episode at his or her specialty practice. This helps new and younger physicians meet these doctors and develop a relationship so they feel comfortable making a referral.
Cross-training or co-training can improve communication and deepen relationships. It can be as simple as giving both sides a chance to develop an understanding of what a day in the life looks like for another clinician. That knowledge can lead to discussions about making meaningful changes for the patient while providing more satisfaction among providers.
Equally important is presenting information that doctors find valuable and engaging. In other words, helping physicians and clinical staff tie what they do to the broader picture will keep them more engaged.
To increase the attendance of primary care physicians at a networking program called Physician Connect, Lipman asked the leaders of the physician advisory committee to brainstorm topics that would appeal to this audience. These included presenting ProHealth's three-year strategic plan, as well as the organization’s governance structure. The results? There were nearly 30 primary care doctors who attended the meeting — a marked improvement from the year before.
Using technology and analytics
Analytics and technology — using a shared electronic health record, for example, or notifying a physician, via health information exchanges, of a patient’s admission — can improve inpatient and outpatient communication. Moreover, there are methods to automate communications for the care team so that everyone is aware of developments.
Lipman said ProHealth is exploring other communication methods, such as the messaging tool in Epic and an internal, interactive blog available to administrators and physicians so they can discuss issues electronically.
“That is the way younger physicians coming out now feel very comfortable communicating,” Lipman said. “Like my kids, they won’t answer the phone, but they will answer my text, right?”
As beneficial as technology can be to improving communication and positively influencing the patient experience, something as basic as including a picture of the physician and describing his or her role on the care team can be effective.
Evaluation and evolution
While there will certainly be common themes in different markets, every inpatient and outpatient physician coordination situation will be different. Therefore, building an unbiased evaluation forum can ensure that your efforts to improve primary care and specialist physician relations are meeting stakeholders’ needs.
Seek feedback constantly and integrate it into system processes that include rounding on patients, physicians and staff. Through a continuous feedback loop, administrators can share progress on reducing barriers. Undertaking an ease and impact study can help determine how difficult the change is and where the system will achieve the most gains.
Lipman says communication between hospitals and primary care physicians has significantly improved. Building the governance structure in a multispecialty employee group helps him understand opportunities to create networking.
“You can’t just have an annual meeting or an independent group meeting,” Lipman said. “You have to create multiple venues at different times and understand that physicians are going to take a little bit of time to do the things that we have been talking about.”
Kearin Schulte is a director at Huron in Chicago.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.