Efficiency and timeliness in care are two of the Institute of Medicine’s six “Aims for Improvement”. Those are literally “million-dollar” topics for your institution, as millions are wasted annually due to throughput inefficiencies and increased length of stay.
A huge rate-limiting step in our daily workflow is waiting for consultant recommendations. Throughout my career, and practically every day when I’m on service, I have found myself asking consultants, “Do you know when you’ll get a chance to see…?” Since a big part of our job is coordinating care in an efficient and timely manner, we often find ourselves adapting our everyday practice habits to meet that goal.
To examine this issue and identify potential solutions, I conducted a study at my institution, the Ohio State University Wexner Medical Center, examining indirect vs direct communication with consultants for new consults.
First, a few definitions crucial to the project:
- Indirect communication: Placing a consult in the EMR
- Direct communication: Placing the consult in the EMR followed by verbal communication with the consultant regarding the reason for the consult
- Consult turnaround: Receiving formal recommendations from the consultant either verbally or via notification from the consultant that their note was in the chart
Compared with consults placed using indirect communication, those placed using direct communication prior to noon had a 50% reduction in turnaround time, and those observed between noon and 5 p.m. experienced a 17% reduction in turnaround time. As a result, consultant recommendations were available much earlier in the day and were more likely to be implemented the same calendar day.
Despite the obvious benefit, our services still struggled to do this consistently. One of our major barriers was the inherent time constraints we have in our day. No one has the time to page and then wait and wait at a phone for a call back. But as much as some would like to believe that consultants are screening our pages, that’s not the case. Just as we have our competing demands, often theirs (clinic, procedures, lectures, etc…) get in the way of them providing a timely response.
In efforts to overcome these barriers, we obtained and assigned service-specific wireless phones. That way, one could page to their phone and go about their day. Of course, calls may be returned at inopportune times (in a patient room, meeting, lecture, or when nature is calling), but this is a far superior option than waiting by a landline or not communicating directly at all.
We also recently adopted secure HIPAA compliant two-way text messaging. We initially trialed DocHaloTM but ultimately switched to secure messaging within the EPICTM mobile app. Both platforms have a useful read receipt feature which allows the sender to know exactly when the message was viewed. This year, I’ll be undertaking a second phase in my project where I’ll examine if secure messaging, as a form of direct communication, yields similar results to what I found in phase 1. I hope to share my findings with you next summer.
Both interventions helped us make strides in the right direction, but consistency in practice habits and universal buy-in across the institution continue to be obstacles. It’s easy to become disenfranchised with direct communication when other services do not reciprocate to the degree yours may.
My division’s philosophy is to lead by example in hopes that our colleagues across the institution follow suit. Thus far, I’ve noticed a significant difference in the number of calls I get from consultants with verbal recs hours before their notes are in when I’ve taken the proactive approach to personally speak with them. These preliminary results should hopefully be the inspiration your partners need to adopt direct communication to improve throughput and possibly decrease length of stay and cost of care.
Good luck! Keep up the good fight. Our patients deserve nothing less.
Note: I’m always looking to collaborate, so if you have any project ideas in the areas of QI, patient safety or patient experience, let’s chat!
Chirag R. Patel, DO, SFHM, FACP
The Ohio State University Wexner Medical Center