Sunday, March 15, 2009

The importance of communication

I had a difficult day last week. A patient came in with two reports: one (from a downtown hospital) showing a decreased bone density, and a second (from a different downtown hospital) showing some compressed and fractured vertebrae. This patient needs medication for osteoporosis. The issue for me was that neither of these reports were sent to me, and there was no treatment. The patient was seen at hospital #2 for a different reason; a physician gave her the report and told her "if I was your family physician, I would treat you". The patient handed me both reports. The report from hospital #1 had my name on it, but was never sent to me. The patient's comment was that the system seemed to be failing her. I agree.

Our current College of Physicians and Surgeons magazine talks about the importance of communication; the article discusses two plane crashes that happened because of poor communication between flight crew, cabin crew and flight control. When this happens to planes, there is an investigation, and they figure out what happens and how to prevent it in the future. The CPSO's comment is that "the more complex the system, the more sophisticated the communications"; health care is at least as complex as aviation, if not more.

A problem in health care is that we often don't learn from our mistakes, so we just repeat them. The example above will go unreported, unsolved, and unimproved. We have the technology and the ability to send reports electronically today (my labs come in this way), but I continue to receive most of my reports by fax or mail (or via patients). The reasons why this is happening are multiple:
-other priorities
-lack of money
-lack of time
-the tragedy of the commons (this is an issue that affects everyone, but is no-one's responsibility in particular)

The error above occurred due to multiple systemic factors; however, there is no agency responsible for investigating this or for recommending a better system of communication (send it to me electronically). Each individual hospital has their own individually maintained address book (with all the attendant problems that these duplicate entries entail), and there is no obligation to send reports back to the family physician if he or she didn't order the test. The ordering physician cannot reasonably forward all tests to the family physician. The list of rostered patients (which patients are registered with which family physician) exists at the Ministry of Health, but is in no way tied to any of the hospital's physician address books. The CPSO mandates that we give it an updated list of addresses and contact numbers, but this database is separate as well. We need to make sure that all this information is securely tied together (with all privacy safeguards).

Everyone in my practice team (physicians, nurse, front staff, administrator, social worker, dietitian, clinical pharmacist, residents) is now using the EMR; there is no paper record. We communicate via the record. If there is a problem, I get an electronic message, and it is tracked--and I want to hear about it. I recently had a difficult mental health issue, and my social worker sent me a message remotely, which prompted me to call the patient--the chronological story was recorded in the record.

A physician in my group was not receiving her pap results; I believe that a database error at the lab caused them to be sent to the wrong location, and the other office simply bounced them back to the lab. They were never forwarded. It takes 3 months for us to get our paps back, making it difficult to remember who had the test. Because this physician had decided to generate her pap reqs within the EMR, she was able to generate a list of all pending paps so these could be tracked. We know that the system sometimes fail us and fails our patients; being able to track things in the EMR has a lot of value; you would think that everyone recognizes this, but that is not the case--and sometimes the problem is one of communication.

One of my electronic reqs for Diagnostic Imaging was rejected, because it did not look like the standard paper req. My problem was that I became so upset by this that I was going to make the issue worse by not communicating; I decided to phone instead (after calming down a bit), and they were more than helpful in helping me to resolve this. The problem turned out to be that the person receiving the reqs at the front had not been notified, and found the fonts too small. I can understand this; I'm also a bit past high noon, and can't suture without drugstore glasses anymore. Communication is a two way street; it will take a lot of it to change this system.

This enormous process of change that we are undergoing is a social one. In this system, we function as independant units far too often, and we need to start talking to each other more. The EMR is of incredible value in enabling this type of communication; there is no one in my practice team who would go back to the old way. However, EMRs are still isolated within the whole system, and we continue to have far too few electronic links. Perhaps once we can talk more, we will talk more and better; as the CPSO puts it, "among health-care teams (and in any field), the best communications feature a clarity of roles, a unity of purpose, the ability to not just carry out orders but share ideas, and respect for each other's professionalism and views. That's what will allow any team to take flight."

Ministries and regulatory agencies need to recognize this need for communication, and to enable it. This can't be the responsability of individual teams alone.