Exploring Ideas for Improving Exploring Ideas for Improving Care CoordinationCare Coordination
Eric A. Coleman, MD, MPH
Associate Professor
Divisions of Geriatric Medicine and
Health Care Policy and Research
University of Colorado Health Sciences Center
4 Key Areas for Change4 Key Areas for Change
1) Develop systems to notify patients of test results2) Develop processes for better communication
between primary and specialty care3) Medication reconciliation4) Coordination outside of office hours
Lab Result ManagementLab Result Management
““Where no news is not Where no news is not necessarily good news…”necessarily good news…”
Burden of Test Result Management Burden of Test Result Management
Per week, full-time PCP needs to review:
– 360 chemistry results (SMA7 = 7)– 460 hematology results– 12 pathology reports– 40 radiology reports
Physician PerspectivePhysician Perspective
43% of physicians surveyed report being satisfied with the way they manage test results
83% report experiencing a delay in reviewing lab results with potential to adversely affect care
Implications for:– Efficiency– Safety– Risk management
The Black Hole??The Black Hole??
25% of physicians routinely inform patients of normal lab results
67% of physicians routinely inform patients of abnormal lab results
24% had a reliable system for identifying patients overdue for f/u labs
What Can We Learn What Can We Learn from the Literature?from the Literature?
33% of abnormal TSH values do not receive timely follow-up
36% of abnormal pap smear are ‘lost’ to follow-up
25% malpractice claims due to failures in follow-up
Lab Management—3 Main StepsLab Management—3 Main Steps
Retrieve and review resultsCommunicate and interpret results to
patientsIncorporate findings into care plan
Break It Down—Test ResultsBreak It Down—Test Results
Protocol for normal results, no action required Protocol for normal results, action required Protocol for abnormal results no action required Protocol for abnormal results action required Protocol for abnormal results urgent action
required Protocol for detecting when test not obtained
Communication StrategiesCommunication Strategies
Pre-formatted letters for sharing results with patients on paper
Portal to EMR to allow patients to view once MD as released
Phone calls for abnormal resultsE-Visits for abnormal results (with appropriate
time compensation)
Lab Tracking ToolsLab Tracking Tools
Paper Forms EHRS/EMRPatient Portal/web access (after MD releases)MS AccessMS Outlook
Using MS Outlook to Track LabsUsing MS Outlook to Track Labs
Most clinics already have the software – Low cost approach; – free self-guided tutorial– However, all tracking systems require up front time
Track a test from the time it was ordered to the time that the results are given to the patient using built-in features
Will provide reminders or warnings when a task is overdue or a test has not returned
Can also generate mailing labels to mail results to patients
Improving the Referral ProcessImproving the Referral Process
Communication BreakdownCommunication Breakdown
Lack of clarity over reason for referralDisruption in continuity of careDelayed diagnosisUnnecessary/duplicative testingDissatisfaction by all parties
Generalist/Specialist Generalist/Specialist CommunicationCommunication
Specialists report receiving information 32% of the time
Generalist report getting referral letter 55-80% of the time
Patients are a “silent partner” who may self-refer
Two to TangoTwo to Tango
63% of PCPs dissatisfied35% of Specialists dissatisfiedRoom for improvement on both ends
Improving the Referral ExperienceImproving the Referral Experience
Redesign flow of informationReferral agreements between IPA and Practice
for how communication will occurClearly stated referral questions and answersFriendlier consultant letter formatState preferred method of communication
Referral AgreementsReferral Agreements
Service requested:– Evaluation– Evaluation and initial
management– Evaluation and
ongoing management– Procedure– Second opinion– Other
Reason for referral Preferred
communication– Fax– Email– Voicemail– Mail– Other
Care Coordination Out of the Care Coordination Out of the OfficeOffice
Develop a Flow Chart or Develop a Flow Chart or ‘How To Guide” for Clinic‘How To Guide” for Clinic
How do I get an appointment?How do I get my labs?How do get I care from specialists?How do I get care after hours?
After HoursAfter Hours
Flow diagram—care seeking after hoursAnswering machine that says “go to ED” not
acceptableDon’t have too solve problem 100%--call back in a
few hours to see how they are doingInitiate first steps of therapy (UTI, hyperglycemia)Malpractice concerns—need documentation
Out of Hours—Telephone ChartingOut of Hours—Telephone Charting
Move to Action!Move to Action!What is the status quo in your clinic?What advice would your patients give us?What have you tried?
– What went well?– What did you learn?
What will be your next PDSA?What tools or resources will you need?
Medication ReconciliationMedication Reconciliation
Medication ReconciliationMedication ReconciliationWhat Are We Looking For?What Are We Looking For?
Create a single listIdentify discrepancies (incompatible regimens)Drug/Disease=pertinent positives and
negativesDrug/Drug=most common, most serious
Engaging the PatientEngaging the Patient
Encourage patient to bring all medications or list to every encounter
Provide with a dedicated tote bag Key=> must positively reinforce behaviorInitial MA or RN review
Scripting Patient CareScripting Patient Care
Coach or give permission to speak up:– Every time a prescriber takes out a prescription pad,
ask “would you like to see my medicine list” or “will this new medication interfere with my current meds?”
My Medications are:
Medication Dose
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Allergies: _____________________
Reason Side Effects
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Personal Health RecordPersonal Health Record
Remember
to take this Record with you
to all of your doctor visits