This article is from June 2007 and may contain outdated material.
When James A. Garrity, MD, had trouble explaining a patient’s postoperative vision loss, he enlisted the help of his colleagues. “I just picked up the phone and said, ‘Can you come over and take a look?’” Dr. Garrity, a neuro-ophthalmologist at Mayo Clinic, was confident that his call would be answered because at Mayo, an organization of salaried physicians, collaboration is part of the culture. “We interact and depend on the assistance of other specialties,” he said.
“There are a lot of interdependencies in health care,” said Michael F. Chiang, MD, who is assistant professor of ophthalmology and biomedical informatics, Columbia University. “What one doctor does affects another physician’s domain. The challenge is that doctors have to be able to share information about these patients.”
Though there are few incentives in more traditional practice settings to stop everything and make a phone call, let alone return one, collaboration has never been more important. Today’s patients are mobile, and they are frequently cared for by multiple specialists. Gone are the days when one family doctor provided medical care from cradle to grave. For eye medicine alone, it’s not unusual for one patient to have three or four ophthalmologists over the course of many years. Today, a cataract surgeon may need preoperative information from a refractive surgeon. Or a retina specialist may need to exchange information with a patient’s internist or nephrologist. Neuro-ophthalmologists work closely with neurologists, and they may collaborate with endocrinologists for patients with thyroid and pituitary disease. A rheumatologist may administer uveitis medications. In this age of increasing specialization and patient mobility, nobody can afford to go it alone. At stake is nothing less than patient safety, not to mention the doctor’s peace of mind.
Good Decisions Need Whole Histories
Before Paul J. Lama, MD, decides whether to operate on an eye, he wants to know the patient’s total health picture. “A lot of patients have multiple medical problems and their lifelong prognosis is not so good. This affects how aggressive your treatment will be,” said Dr. Lama, who is both a glaucoma specialist and an internist. “That’s where communication is important. How sick is the patient?” said Dr. Lama, who is an assistant professor of ophthalmology and associate director of glaucoma at the University of Medicine & Dentistry of New Jersey. The best way to get that information is to call the other doctor. “Like any other appointments you set up during the day, with the biller or office manager, you’re going to set up the five minutes to make the call,” Dr. Lama said.
“We’re all pressed for time,” acknowledged retina specialist Abdhish R. Bhavsar, MD. Nevertheless, he makes the effort to work with other doctors, especially when a patient has advancing retinopathy. “I pick up the phone for those circumstances where I think the patient doesn’t really know what’s going on with their own care,” said Dr. Bhavsar, who is director of clinical research at the Retina Center in Minnesota, and chairman of the state’s Diabetes Eye Exam Initiative
Real-world examples. Failure to communicate can have unintended consequences. One of Dr. Lama’s pa-tients had a stroke during a glaucoma procedure, probably because the in-ternist had stopped the patient’s warfarin (Coumadin). Dr. Lama said internists often discontinue antico- agulants prior to any kind of eye sur-gery, though in this case there was no reason to do so. “It’s important for the ophthalmologist to convey to the in-ternist the relative gravity of the situation,” he said.
On the other hand, communication led to a more favorable outcome for a patient who told Dr. Lama she got fatigued after taking oral beta-blockers for her coronary disease. After observing that the patient’s IOP had remained elevated on every other medication, Dr. Lama called the patient’s cardiologist and said he’d like to try the beta-blocker before advancing to glaucoma surgery. The cardiologist gave him the go-ahead, explaining that the patient had received stents, which should have alleviated the fatigue.
Dr. Bhavsar is especially mindful of the need for collaborating on patients with diabetic retinopathy, where the underlying diabetes may affect multiple organs. “I am very meticulous about sending correspondence to other eye care providers, and, even more important, to the internist, family doctor or endocrinologist who is helping to care for the diabetes,” he said, explaining that the eye is the only end organ that other doctors can’t measure effectively. In return, he needs to know the patient’s HbA1C, renal and fluid status, as well as blood pressure. Dr. Bhavsar checks blood pressures, but wants to know from other providers how they’re trending.
Collaboration = Communication
No one is big enough to be independent of others.” That statement has been attributed to Will Mayo, one of the founding brothers of the world-famous clinic, where collegial interdependence is a touchstone for medical practice. How can teamwork be fostered in more traditional practice settings, especially in today’s hurried environment? Here’s what some experts say:
Electronic medical records—here for good. “Physicians need to communicate with other physicians now more than ever,” said Dr. Chiang, who is a proponent of electronic transmission of patient data and a member of the Academy’s Committee on Medical Information Technology. “The current system involving paper and x-ray film doesn’t work anymore. We need to develop strategies for doing this electronically.”
An electronic system would avoid situations where the patient doesn’t know his or her medical record, or has to repeat the same medical history to every physician. “If they forget their meds, there’s a way to pull that up. You can know what other physicians’ impressions were,” Dr. Chiang said. Also, those physicians will know about your exam. True, there’s nothing new about electronic medical records. The problem is that everybody is speaking a different language. To that end, the Academy has been working with developers of SNOMED (systematized nomenclature of medicine), to include more ophthalmic terms in that system’s vocabulary. The precedent for seamless communication already exists, such as ICD-9, used for diagnostic coding, and CPT to code for reimbursement.
Roentgen role models. Many radiologists already communicate digitally. At most academic medical centers they no longer use x-ray films, and instead create and read all images on digital systems, from which images can be electronically transmitted from one location to another. “Radiology is a good lesson for us,” said Dr. Chiang. “Unless we have some way of being able to transmit these medical records, patient care suffers. One physician doesn’t know what the other is doing,” he said. “We’re moving in the right direction,” he added, but physicians should start demanding a common standard. Then vendors will be more motivated to share terminology and communication standards.
Online services. The sharing of medical records via the Internet is one way to keep referring physicians in the loop after they’ve sent a patient to another doctor. James Bolling, MD, has helped develop a system for doing just that. The system, e-Health access, facilitates communication between Mayo Clinic physicians in Jacksonville, Fla., and 300 of the region’s referring physicians. (The goal is to double the number of participants in the next year.)
Physicians who refer patients to Mayo Clinic have electronic access to their patients’ medical records, and can keep tabs on any ongoing treatment, said Dr. Bolling, who is chairman of the Jacksonville Information Technology Committee, Mayo Clinic. The e-Health system, which is accessed over the Internet through a secured gateway, “facilitates communication with referring physicians and it helps share information,” he said.
One form fits all. A few years ago, Dr. Bhavsar helped design a faxable checklist form that was intended to facilitate communication between ophthalmologists and other health care workers involved in the care of diabetes patients. The one-page form was developed for the Diabetes Eye Exam Initiative in Minnesota, and was placed on the Minnesota Academy of Ophthalmology Web site (www.mneyemd.org). “The idea was to make it easier for the ophthalmologist to really communicate effectively without having to dictate a note or type a note separately,” Dr. Bhavsar said.
Other organizations have adopted similar forms. The Academy has a downloadable fax-back form at www.aao.org.
Collaboration as a Performance Measure
On a more practice-based level, a doctor’s performance may actually be assessed by the quality of his or her communication with other physicians. Dr. Bhavsar cited a situation involving an insurance company audit of an internist’s records. The company, which was looking for evidence that the primary care physician was sending his patients for eye exams, as well as receiving information back on those exams, wasn’t satisfied with the follow-through from a particular Eye M.D. While there were concerns regarding the manner in which the audit was conducted, the intent was appropriate, Dr. Bhavsar said. “They’re asking for people to communicate more effectively. Without communication between physicians, appropriate care for patients cannot be performed.”
Poor communication also has risk management implications. OMIC risk manager Anne M. Menke, RN, PhD, said, “From a risk management perspective, the biggest problems are the lack of a hand off when physicians are going on and off call and the failure to document physician-to-physician communication.” She said that lack of collaboration is such a huge problem that the American Society for Health Risk Management is devoting an entire conference to the subject. “Teamwork, which has patient safety implications, is getting a lot of attention,” she said.
Everybody wins. But fear shouldn’t be the only driving force behind collaboration. “I learn a lot from my colleagues,” Dr. Garrity said. “And professionally, it’s quite stimulating.”
Collaboration may also be an antidote to loneliness. “Given the great flux in retinal treatments today, and all those complex decisions we’re trying to make in terms of treating the patient in front of us, we can feel like we’re in a vacuum sometimes,” Dr. Bhavsar said. “But we’re not alone. There are other physicians who can help us greatly in managing the patient. We’re managing the local problem that we’re identifying in the retina, but they can help us globally with management of the rest of the patient.”