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Healthcare Reform Barrier: When the ER Doesn't Talk to Your Doctor

When 32 million more people get healthcare coverage in 2014, the quality of their care will depend to a large extent on how well emergency docs communicate with primary-care physicians. That's partly because so many people have to go the ED when they can't get in to see their regular doctor -- if they even have one.

Unfortunately, as a recent study shows, communication between ER doctors and office-based generalists remains awful. If that situation doesn't change, extending coverage to more people may not make them much healthier -- and it certainly won't do much to get healthcare costs under control.

In the study, the researchers interviewed 21 pairs of primary and ER docs, each linked to the same hospital. What they found:

  • ER and primary care doctors agreed that the telephone was the best way to communicate;
  • Both sets of doctors often had trouble getting the other party on the line;
  • Doctors eventually decided that phone tag wasn't worth the time it took, especially since they weren't getting paid for it;
  • Many docs turned to faxes instead, but that also took time and didn't provide any opportunity for interaction.
Shared electronic health records (EHR) seem to offer a better solution. In theory, they could allow ER doctors to view a patient's medical history and alert the primary care doctor about the visit. The primary physician could also see what was done in the ER.

But hold on a second. The researchers commented:

EHRs are not yet designed to offer a rapid overview of a patient's case that is relevant to a particular problem with the level of detail that could help an emergency provider direct care.
I'm not sure exactly what that refers to. But there are relatively few healthcare systems in which ER and ambulatory-care providers use the same EHR or have an interface between disparate EHRs. In any case, it's evident that the information available to most ER providers when they see new patients is still inadequate.

There are other barriers to communication, including:

  • The rise of hospitalists, which has led to fewer primary-care doctors working in hospitals and having personal relationships with ER doctors
  • Cross coverage in large groups, which makes it difficult for ER physicians to locate a patient's primary care doctor
  • Malpractice liability concerns, which make some doctors reluctant to get involved in a patient's care outside their office.
In addition to these problems, fully half of the newly insured people will be on Medicaid. Even if local doctors are willing to take those patients -- only 42 percent of U.S. physicians are -- many of these patients are used to getting their care in the ER. So it will take a concerted, collaborative effort by ER physicians and primary care doctors to convince such patients that they'd be better off if a personal physician coordinated their care.

The biggest issue is that there simply aren't enough primary care doctors to handle the impending wave of patients. The states with the lowest per capita number of primary physicians, another study found recently, will also have the largest increases in the number of Medicaid patients three years from now. So ER doctors are likely to be overwhelmed by patients, which means they'll have even less time to coordinate with primary care doctors.

There's not much that can be done about this short of revamping our entire care delivery system. And even then, it will take years before the supply of primary care doctors is equal to the demand.

Image supplied courtesy of U.S. Army.

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