Using EMRs to close the communication gap between PCPs and specialists

“Closing the loop” is an important concept in coordination of health care, which refers to good communication between referring physicians and those clinicians who receive the referrals. Much needless healthcare cost results from a poorly coordinated and fragmented healthcare delivery system, where duplication of testing frequently results from poor communication.

There are two elements to good communication between referring physicians (often Primary Care Physicians – PCPs) and the specialists to whom they refer: (1) good documentation as to why the referral is being made – what is the clinical question being asked – and a forwarding of the relevant information already at-hand (lab tests, imaging studies already done, correspondence from other specialists already consulted, etc.); and (2) feedback from the specialist in answer to the question at-hand, along with diagnostic and treatment recommendations, including who-is-going-to-do-what.

Frequently, specialists will complain that they receive referrals from PCPs that are inappropriate, inadequately worked up, or with minimal referral information (a patient who may have a significant background history of testing and therapy referred to an orthopedist for “back pain” without any other information forwarded). Worse, sometimes a patient will show up in the specialist’s office as a “cold visit,” and the specialist needs to ask “so, why are you here?”

On the other end of the “loop,” PCPs will often complain that they receive no feedback from some of the specialists to whom they refer. The patient returns to the PCP and states “I saw Dr. x and she changed a bunch of my medications, and I am confused about what to do” – and no information is available to the PCP. Or, “Dr. x ordered a bunch of lab tests on me, and so did you, so I had them all done.” Frustrating, but a common experience in clinical practice.

In clinic-model healthcare settings (such as Kaiser, or similar staff-model settings), this issue is addressed by having a common chart for a given patient, which is shared by all clinicians – PCPs and specialists – and therefore duplication is reduced. This is similar to an inpatient hospital chart, where a single chart is shared by everyone involved in the patient’s care during the current admission.

In the more common ambulatory setting, every physician keeps her own separate chart on the patient. And a given patient may see as many as 18.7 physicians– meaning that there are 19 or more different charts scattered around the healthcare landscape. Risk-taking IPAs and other Accountable Care Organizations have devoted significant attention to ways of “closing the loop.”

The impact of Electronic Health Records (EHRs) on all of this is potentially huge. Several Meaningful Use criteria for EHRs address referrals and data interchange. One element is capturing Referral information as part of ambulatory Computerized Physicians Order Entry (CPOE) – which should lay the groundwork for adequately sending relevant clinical information from a referring physician to a specialist. Another element is creating a standardized way that clinical data can be transmitted between disparate EHR systems (which, of course, assumes that both ends of the hand-off have Certified EHRs capable of exporting and importing such CCR or CCD files). This may become commonplace some time down the road, but the groundwork for “getting there” is being laid now in the HHS Certification process.

An additional, and potentially more powerful, way of “closing the loop” is Practice Fusion’s Chart Share project. Though still being tested in beta, this feature allows different practices to be able to share common charts. Of course, by design, all practitioners within a given practice (and there is no limit on how many practitioners can be grouped into a single, even multi-site, practice) can share all the practice’s charts. However, between distinct practices, Chart Share allows a referring practice to grant permission to a recipient practice to see a specific referred patient’s record. Exactly what elements of such a shared chart should be shared, as well as numerous questions about permissions, are being carefully worked out (which is why it is still in beta) – but, conceptually, this is a powerful path towards “one patient, one chart.” And it doesn’t really matter whether/if the recipient is using some other EHR or not – Practice Fusion is web-based, and can be set up in minutes. Clinical information can be seen via Chart Share side-by-side with whatever other system (if there is one) that a referred-to clinician is using.

“Closing the loop” is a shorthand way of describing the need for more-coordinated healthcare. Systemic changes need to occur in how our fragmented healthcare delivery system functions in order to accomplish this effectively. EHRs, when well designed and forward-looking, are tools that can significantly help in this process – the goal here is that waste and duplication can be minimized, improved quality of care through effective communication can be realized, and at the same time the local ambulatory-practice basis of personalized healthcare can be maintained.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR