Coordinated Care

21st-century referrals: Medical homes, EHRs, networks are streamlining care

Health system changes are already improving quality and cost-effectiveness of care for some DOs.

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Although many may feel overwhelmed by the rapid pace of health system change, some osteopathic physicians contend that certain developments are already improving health care quality and cost-effectiveness. As practices adopt electronic health records, embrace the patient-centered medical home model of care and become part of larger multispecialty groups and networks of physicians, care coordination is becoming easier, these DOs say.

Physicians refer their patients to other specialists roughly 10% of the time, a proportion nearly double that of a decade ago, according to a study published in 2012 in JAMA Internal Medicine. The referral process historically has been cumbersome, requiring patient information and reports to be copied and mailed or faxed and images to be hand-delivered by patients.

When they lack easy access to critical information, non-primary-care specialists have been known to order duplicate diagnostic tests and write prescriptions for medications that may replicate or interact adversely with drugs patients are already taking.

What’s more, referring physicians traditionally don’t track their referrals, relying on patients to make the needed specialist appointments on their own.

But EHR systems and new practice configurations are altering this picture.

Better communication, follow-up

A family physician in Pottstown, Pa., Carol L. Henwood, DO, practices in a multispecialty group of approximately 50 physicians—with eight primary care sites that have all been recognized by the National Committee for Quality Assurance (NCQA) as patient-centered medical homes.

“Given that all of us providing primary care in our group are medical homes, we have policies and procedures in place that promote coordination of care. So we don’t have duplicate testing. Patients’ appointments are made for them, and we receive monthly reports indicating studies and tests that were ordered but not done,” says Dr. Henwood, the president-elect of the American College of Osteopathic Family Physicians (ACOFP).

A key aspect of care coordination is managing transitions between care settings. When patients are released from hospitals, they don’t always adhere to discharge instructions and make recommended follow-up appointments with their physicians. As a result, hospital readmission rates tend to be high.

But in a patient-centered medical home, a nurse or other staff member in the primary care physician’s office would contact the patient within 48 hours of discharge to find out how he or she is doing and make sure that medications are being taken appropriately and needed lab work and follow-up office visits are scheduled, notes AOA 2nd Vice President Ernest R. Gelb, DO, whose previous practice was a Level 3 NCQA medical home.

“Transitions between physicians and between institutions have been a patient safety issue,” says Robert G. Good, DO, the president of the American College of Osteopathic Internists. “The patient-centered medical home model helps physicians coordinate care in a better fashion than we did in the past.”

Economies of scale

While solo and small group practices can derive benefits from adopting EHRs and becoming medical homes, larger physician organizations may have an edge when it comes to streamlining referrals.

Being part of a group that includes cardiologists, pulmonologists, gastroenterologists and other internal medicine subspecialists—all of whom are using the same EHR system—facilitates care coordination, notes Dr. Henwood.

“If I send a patient to a cardiologist in our group, for example, he or she has access electronically to all of the patient’s previous studies, including electrocardiograms and stress tests,” she says.

One advantage to working for a large multispecialty group on a common EHR system is that patients’ appointments with specialists do get made, says AOA Trustee Joseph M. Yasso Jr., DO, a family physician in Independence, Mo., whose practice group is owned by Hospital Corporation of America (HCA). “We make most of our referrals electronically for the patient. The specialist’s office then contacts the patient by phone to set up an appointment time,” he says.

Employed by Botsford Hospital in Farmington Hills, Mich., geriatrician Annette T. Carron, DO, says that being part of a health system or a large physician organization that uses EHRs makes care coordination “much more seamless.”

“Primary care physicians within our health system electronically send me referrals, which include the patient’s name, diagnosis and insurance information. The appointment is set up within the EHR, and the patient gets a printout with the appointment information and our location,” she says.

Inside versus outside consultations

On the other hand, could being part of a large EHR-connected physician network actually restrict referrals to the detriment of patient care?

“As more and more independent doctors leave individual private practice for the security and economy of scale of group practice, referral patterns could dramatically change due to the concept of ‘group think’ and the inclination to keep referrals within the confines of the group as much as feasible,” suggests Dayton, Ohio, family physician Paul A. Martin, DO.

But a number of DOs who have gone through practice transformations say their referral patterns have not been significantly or adversely affected.

“We are strongly encouraged but not required to use physicians within our own group and refer patients to the hospital that is part of HCA,” says Dr. Yasso. “But in a lot of cases, I refer to the same doctors that I referred to before I went to work for HCA.”

Patients can choose where they want to go, Dr. Yasso points out. “If a patient decides not to go to an HCA affiliate, I’m not going to argue with him or her,” he says.

“Using an electronic system has not changed my referral pattern,” says Dr. Good, a general internist in Mattoon, Ill., who is employed by a 400-physician multispecialty organization. “I refer to the same subspecialists I have always referred to.

“I refer consistently to the people who are best-qualified to address patients’ problems, whether they are in my group or out of my group. However, I have a very good group, which makes it fairly easy to refer inside our organization because my consulting physicians are quality people. But I’m referring patients to physicians who provide the best care, not just because they are in my group.”

Dr. Carron maintains that referral patterns have not been compromised by the ease of communicating with inside versus outside consulting physicians. Driven by each patient’s needs, hospitals sometimes transfer patients to other hospitals that are stronger in certain areas, she notes. Botsford Hospital, for example does not have many pediatric subspecialists, so children with severe medical problems are often referred to other institutions.

And Dr. Carron generally refers her patients who need interventional pain management to outside physicians. “Before I make referrals, I visit pain clinics to see whether they are likely to be able to provide the care I’m seeking for my patients,” she says.

In her multispecialty group, Dr. Henwood has observed that non-primary-care specialists and subspecialists have been adopting evidence-based guidelines and some of the tenets of the medical home. She often refers to her colleagues because she can see that they are committed to providing efficient, high-caliber care, she says.

But Dr. Henwood also refers outside of her group when requested to do so by a patient, who may want a physician in a particular location, for example. “What I look for in such referrals is someone who is practicing in accordance with evidence-based guidelines; someone who in the past has provided timely follow-up, whether a letter or a phone call; someone who says to the patient, ‘I want to make sure you follow up with your primary care doctor, then he or she will coordinate your care plan and get back to me.’ ”

Dr. Henwood notes that because of declining reimbursement, some physicians will see patients more often and order more tests than they need to. “I really believe that we all have a responsibility, regardless of specialty, to provide high-quality, cost-effective care,” she says. “The people that I will send my patients to have not only their patients’ interest at heart but also the U.S. health system’s interest at heart.

“The U.S. spends too much of its gross domestic product on health care. If we collectively do better as physicians, then health care will be more affordable for everybody.”

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