Provider Communications in the Murky Middle
February 08, 2017
When I was a hospitalist, my routine would be to review the EHR, try to find and talk to the nurse, visit the patient, and then document my notes and place orders. The next step was often the most challenging for me: How to communicate my intent or engage in a dialogue with other care team members to make an optimal, collaborative decision.
There were really only four options.
1) Put an order in the EHR
2) Indicate an intent or question in a patient note
3) Look around the unit with the unlikely hope that the consultant or nurse happened to be close by, or
4) Page/call the person.
The easiest path, the EHR, was obviously the right choice for orders such as morning labs and updates in the progress note to the overall care plan. And finding and interrupting the care team member is always the right course of action for a critical question or an urgent, complex decision.
Too Much or Too Little
The challenge was the "murky middle"--when you have a communication that you want to make sure is addressed but does not need to be addressed urgently, especially when there may be a short, directed dialogue between me and the other care team member to get to an answer.
For example, I may round on a patient first thing in the morning and notice her blood pressure is running high and she is on the maximum dose of current medications. The cardiologist is managing the patient's hypertension medications, but I do not know when the cardiologist will see the patient that day, so my question would be "Patient Janet Smith's blood pressure is running high, and I think she should be started on an ACE inhibitor. Should I start her on Lisinopril 10mg PO QDay?" I could leave a note in the EHR, but I do not know if or when the cardiologist will see it. I could ask the nurse to ask the cardiologist when she rounds but that is not reliable. I could place a nurse communication order to "check with the cardiologist before starting," but that is highly inefficient. I could page the cardiologist, but the question is not urgent—certainly not worth interrupting the cardiologist to answer immediately. There was no optimal way to communicate in this common scenario.
In this communication process, I need to accomplish four things:
1) I need to determine who is the on-call cardiologist for the patient that day.
2) I need to know the message was received, and if it wasn't received, I need to find an alternate way of getting an answer.
3) I need to make sure I receive a response in an appropriate period of time.
4) I need to make sure the "loop is closed," and the order is placed, either by me or the cardiologist.
Methods of communication such as the EHR and phone calls do not support this situation. The EHR requires little effort, but it is not the right medium to ask questions. On the other hand, the phone call takes more work and disrupts ongoing workflows, thought processes, and patient conversations, and needlessly decreases the efficiency of care team members when the issue is non-urgent.
The Right Tool for the Job
Although I stopped seeing patients a few years ago, I’ve seen how secure messaging fills that "murky middle" through working with health systems at Spok. A robust secure messaging solution is the right medium for this type of communication. With such a solution, physicians can quickly:
1) Determine the right person to contact with a centralized directory and on-call scheduling integration and view that person's status to know if she is available.
2) Review the status of message delivery to know that a message was received by the individual.
3) Follow the history of the messages I have sent to quickly review outstanding messages for which I have not received a reply.
4) Engage in a non-interrupting, asynchronous two-way communication where I can communicate enough information to be confident the loop was closed.
Our care teams live in the perpetual tension of knowing communication and collaboration are absolutely critical for optimal outcomes, yet struggling with time demands and the need to be constantly focused and mindful. The health systems must support tools for caregivers that make it easier to communicate clinical messages in a manner that does not interrupt clinical care and ensures accountability and reliability. A cross-discipline enterprise-wide secure messaging solution that ties to an enterprise-wide directory and fits into clinical workflows can be the tool that rapidly fills that "murky middle."
By Dr. Andrew Mellin, Chief Medical Officer
Dr. Mellin has almost 20 years of experience as both a practicing physician and healthcare executive. He brings an extensive background in health information technology, including leading physician adoption programs for new technologies and developing innovative clinical solutions. Before joining Spok he was VP, Medical Director at RedBrick Health, where he helped health systems drive employee engagement of consumer-oriented population health and well-being solutions. Prior to RedBrick Health, Dr. Mellin spent 15 years at McKesson in various positions where he served as Medical Director for McKesson’s population health analytics solutions, developed a new real-time quality solution for hospitals, and led physician strategy and product management for the electronic health record. He previously served as Medical Director for Allina Health’s Davies Award-winning implementation of an electronic health record at nine hospitals and 60 clinics across Minnesota. Dr. Mellin received his M.D. from Duke University in Durham, N.C., and his MBA from the University of Minnesota, Carlson School of Management. He trained in Internal Medicine at Barnes Hospital in St. Louis, Mo., and is board certified in Internal Medicine.