Opinion | Improving Collaboration — the Electronic Way

As a primary care doctor, much of my time is spent seeing my patients in the office, reviewing their labs, talking to them on the phone or through the portal, managing their medical conditions, updating all their vaccines and healthcare maintenance, addressing their social and mental health, assessing barriers to their care, doing what we can to get them as healthy as they can be.

And helping figure out if and when they need to see somebody else. Not, of course, another primary care doctor; I want them to stick with me. But often there are issues that come up that need the help of someone else, someone with more specialization, a particular skill set I just may not have.

Knowing Our Limits

Long ago we in primary care have learned to recognize our limitations, when we’ve started to tread into waters too deep. Like if something needs to be cut off, or if someone needs chemotherapy. We have willingly consented to stay where we are, to function in the confines of things we’re comfortable with, diseases acute and chronic that we are used to managing — our comfort zone, if you will.

Every primary care doctor does this differently, setting the limits on how far they are willing to go differently for different conditions. When we start to recognize that something is going on that we need help figuring out, or help managing, then we turn to our colleagues, the specialists and subspecialists. To quote Dirty Harry — played by Clint Eastwood in the 1973 movie “Magnum Force” — “A man’s got to know his limitations.” And, as everyone knows, one of the superpowers of a great primary care physician is recognizing when to ask for help.

So, when we push things as far as we think we can, as far as we’re comfortable, when things just aren’t getting better no matter what we’ve tried, or when we recognize right from the start that something is going on that needs another level of evaluation and management that we can’t offer, we turn to others for help.

Three Ways to Go

In the old days, before our shared electronic medical records, this often took the form of a phone call, or a walk down the hall to speak to a colleague in the same practice who managed these conditions, or else the old “curbside consult” during rounds in the halls of the hospital, or in chance meetings in the hospital cafeteria. “I’ve got this patient with this issue that’s been bothering me, and I can’t quite figure out what’s going on. Do you think this might be X, and do you think you could see them?”

Now things have gotten easier, and hopefully this streamlining of our electronic systems will make things better for us, and better for our patients. For the most part, it seems to have taken on three different forms.

The first and simplest is the chat feature in the electronic health record (EHR), which functions pretty much outside the charts but inside the system, acting like messages on your phone. I used this recently when a specialist who was seeing a patient of mine sent me a chat about something that had come up unexpectedly on a test they had run, and they didn’t know what to do about it. I replied with my opinion, as well as adding on additional members of the patient’s care team and new folks who had special expertise, gathering more and more opinions and ideas until we came up with a plan. It was a “communal curbside,” an electronic table over lunch in the cafeteria.

The second way is the most common, one we’re all very used to using, which is our referral process within the EHR. During the course of an office visit when I think I’ve encountered a problem that I need help on, I can place a referral to a specialist, outlining the reason for the consult and what I’m hoping they are going to add to the care of this particular patient. Often this also happens when a patient calls up about a new complaint, or requests a referral to a specialist for management of a particular condition I don’t take care of.

The newest way that has just kicked in is a really cool new feature built into our EHR system called an E-consult. With this tool I am able to ask a specialist a focused question, looking for an opinion on the evaluation and management of a particular issue, without making the patient come in and see the specialist in their office.

Our specialist colleagues across many different disciplines have started to embrace this system, and as long as we don’t abuse it, we are hopeful that it will improve the care of our patients and streamline the process of getting them to the answers they need. I simply enter the type of specialist referral I’m looking for, what the thorny issue is that has been bothering me (or the patient), and ask for suggestions on the next moves to make — something like, “What the heck might this be, and where should we go from here?”

They are able to review the chart, my recent notes, any relevant labs or imaging, and render an opinion electronically. Luckily, this is also a billable endeavor, and makes the work of the old curbside consult or telephone call both more efficient and now reimbursable work.

Making Everyone Comfortable

Of course, everyone — including the referring provider, the receiving specialist, and the patient — needs to be comfortable with each of these levels of evaluations, and no one should ever be offended if someone recommends escalating, either from a chat to an E-consult, or an E-consult to an in-person office visit.

Right now, due to the vagaries of our systems, the waiting time to get in to see some subspecialists and surgeons can be months. We in primary care are constantly bombarded with phone calls from patients, saying that the referral to this particular specialist you placed for me during the office visit is for a problem they’d like to get taken care of sooner rather than later, and yet they were told that the next available appointment with this particular type of provider is three, six, even 12 months away, and can we do something to speed this up?

Sometimes this “speeding up” takes the form of calling in favors, a quick phone call or an email to a friend in that particular field asking them if they would see a patient for us, and sometimes they are able to oblige. But our hope is that the effective and efficient communication and collaboration that can take place in these other forms, either through the chats for simple issues, or E-consults for more complicated ones, will help make things run smoother and help thin out the wait lists for in-person office visits with these subspecialists and surgeons.

Getting to an answer for our patients in more efficient and creative ways can only make things better.