Communication and collaboration: An elusive goal

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.