Ecosystems: The Emergency Room, Hospitalists, and the Serengeti.

I love Nature on PBS.  Invariably, many episodes feature a locale with a harmonious mix of prey, predators, innocent bystanders, plant stuff, and sundry material.

The beauty of these systems is their balance.  Thousands of years of evolution have produced parsimony; only a higher power can claim ownership of this sacred domain.

Then there is the emergency room.  Dysfunctional prior to the advent of hospital and emergency medicine, it was a system with mixed outcomes—but one that evolved into a workable state of equilibrium.  From the myopic view of the hospitalist however, “we made it even better.” Alternatively, maybe this is what we believe.

Our literature base and perspective stresses the hand-off post discharge, and our role inside the hospital walls.  Have we ever thought seriously about what our increasing presence has done to the PCP-ER doc interface?

My sense is no.   Additionally, based on a few hospitalist friends I questioned, the sentiment was unanimous and similar: “we sorta, kinda, maybe give it thought…but it does not matter, because we improve it in the end.”

I am afraid if the below citation is even half-correct, our attendance and growth in the emergency room has made the PCP-ER gap worse, not better.  This ecosystem is out of balance, and as the authors illustrate, the hospitalist has contributed to its slippage.  This is called subtraction by addition.

I hope you will read this recently released brief from a great organization, The Center for Studying Health System Change, entitled, Coordination Between Emergency and Primary Care Physicians.  The investigators used paired ER doc-PCP interviews (and literature reviews) to analyze the shifting relationships between the two parties.  Quote after quote signals a recognizable message.   As cliché as it sounds, you believe these recitations are theoretical or joke as if they are untruths elsewhere and only occur on your home court:

1.  Highlighting the variation in com­munication, an EP (emergency physician) said, “There are some people that will call every primary—that is just their personal style, and some will never call a primary even if you held a loaded gun to their head.”

2.  “It’s really fragmented and frustrating on both sides,” one EP said. “It’s frustrating for the PCP and for us try­ing to get stuff back. We can’t sit around and wait for two hours for them to call us back.” Likewise, another EP said, “When you’re making the second or third phone call to try and reach the attending [PCP], you lose the desire to keep working at it.”

3.  “If you are in the middle of a rectal exam, you don’t take [the call],” an EP said. “Same with [the PCPs] if they are in the middle of a patient encounter. It’s hard to find a time [to speak] together when you are not disrupting the workflow.”

4.  “The PCPs don’t get involved; we don’t associate any more or see them in the lounge. We just don’t communicate anymore because we don’t see each other anymore.” Primary care physicians who admit their own patients believed they had stronger rela­tionships and better communication with emergency physicians because of their continuing presence in the hospital.

 Sound familiar? 

The conclusions of the paper are varied, but in total, the authors convey a chaotic state where PCPs do not transmit essential information to the ER docs.  Hospitalists are not stepping into the breach to alleviate the problem, a conundrum we contributed to by our swelling minions and absent appreciation for the vanquished PCP.

Mike Radienza spoke of ARRA in an earlier post, and how meaningful use and appropriate allocation of EMR funds could make a world of difference in assisting with information exchanges.  Of this paper’s proposed solutions, an interoperable cloud-based EMR, with PCP integration is the most noteworthy.  However, we need a usable interface, designed for docs with real workflow in mind, and not of the coding sort (read the paper for details, as I do not use jargon for jargon’s sake here, i.e., workflow, interface, etc.).

Take home: hospitalists need to rethink the role of the PCP on the admission front end; how PCP’s have vanished from the ED’s radar screen; how HM practitioners forayed into an “ecosystem” we unknowingly altered; and most importantly, how our presence in designing 2011+ EMR’s is vital for creating a workable ER-PCP-HM biosphere.  

The authors have additional solutions of merit that are worthy of consideration, and the table below cites the core issues:

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Coda:  Fred Buckles: 108 yo WWI veteran on secret to living a long life in 2008:

 “When you start to die, don’t.”

Regrettably, our last WWI vet has passed.  A living legend and legacy, is now gone.  WWI is a memory.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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