It was once commonplace for primary care physicians to seek informal guidance from specialists regarding a patient’s care during a “curbside consultation.” This phrase, still in use today, is said to have come about as doctors walked to a hospital parking lot and paused to talk about a case at the curbside.
Leah R. Garnett, Medical News Today Monday 8 May 2017
Another well-known spot for curbside consultations were doctors-only hospital dining rooms, which, by the early 1990s, had all but been replaced by larger and more democratic cafeterias for families, patients, and medical staff.
In a 1996 article in the Canadian Medical Association Journal, simply titled, “The Demise of the Hospital Dining Room,” Michael Kaye MD wistfully described how informal collaboration between primary care physicians (PCPs) and specialists had become part of a bygone era.
“At lunch, advice about patient care, whether a formal consultation was indicated, ways to resolve differences of opinion, the names of the best person for a task – all of these issues could be resolved, often after only a few moments of discussion. Such goings-on now appear remote, dinosauric!” he wrote.
Can 21st century technology help to overcome the growing physical divide between PCPs and specialists?
Few opportunities for collaboration
Today’s PCPs rarely rub shoulders with specialists in the course of a working day. “I’ve been struck by how primary care doctors and specialists are very separate,” said C. Blake Cameron, M.D., a nephrologist and researcher at Duke University Medical Center in Durham, NC. “It used to be that the primary care doctor would get up early in the morning and do hospital rounds,” and confer with other doctors along the way, said Cameron.
Now, of course, PCPs spend their days in their offices with patients, while hospitalists have taken ownership of some of the PCPs’ former tasks. Informal collaboration between PCPs and specialists – over lunch, in a hallway, or at the curbside – is less common.
As a kidney specialist, Dr. Cameron has a special interest in collaboration with PCPs; kidney disease is often a consequence of other diseases – such as diabetes, heart disease, and high blood pressure – that are managed by PCPs.
“Collaboration is important in kidney disease, as it’s a silent disease. It gets overlooked in day-to-day practice,” said Cameron. Unfortunately, as many as half of people with kidney disease are unaware that they have it, added Cameron, as there are often no overt symptoms.
Creating a ‘virtual medical neighborhood’
While a Fellow at Duke in both nephrology and clinical informatics, Cameron became interested in addressing the problem of undiagnosed chronic kidney disease (CKD) in primary care through the concept of a “virtual medical neighborhood.”
He said he realized that deficiencies he saw within CKD care were symptoms of a lack of communication and collaboration within the healthcare system.
To remedy this all-too-common problem in United States healthcare, in 2006, the American College of Physicians released a policy document calling for fundamental changes in how healthcare is delivered and paid for in the U.S. The report advocated a “medical home” approach, in which primary care services are continuous, patient-centered, and coordinated, rather than episodic, disease-oriented, and fragmented.
The medical home concept gained traction in policymaking circles. By 2008, the National Committee for Quality Assurance, the Joint Commission, and others launched medical home accreditation programs in the U.S.
These accreditations require sweeping changes in the organization and delivery of care, and they include a stronger focus on patient-centered care, as well as more effective collaboration between the physician and other health professionals – both physically and virtually.
The term “medical neighborhood” describes the medical home’s close and complex relationship to myriad other parts of the healthcare system, such as specialty physicians, hospitals, nursing homes, and physical therapists.
While the term “neighborhood” conjures up images of streets and sidewalks, the geographic footprint of primary care is vast. The nearest specialist “neighbor” could be miles away.
Cameron saw an opportunity to use electronic communication tools to overcome geography and to make collaboration within the medical neighborhood “virtual” rather than physical – therefore restoring the “curbside” to the modern era.
The medical home is still a relatively new concept and remains a work in progress. However, the electronic components of the framework are becoming a reality, as they are supported by existing web-based tools and the electronic health record (EHR).
|A three-pronged approach|
|Cameron and his colleague Kevin Shah, M.D., medical director for Primary Care Improvement and Innovation at Duke University Medical Center, received seed money from the Duke Institute for Health Innovation (DIHI) to approach the virtual medical neighborhood for CKD from three angles. These are:|
|1. CKD Help Desk|
|Standardized treatment maps for Duke PCPs that suggest initial steps for CKD evaluation and treatment are in development.|
|2. Electronic consultations|
|For more complex concerns, kidney specialists provide advice and guidance to Duke PCPs through written communications in the EHR, without directly seeing or interacting with the patient. These “eConsults” address the need for further testing, treatment, or an in-person referral.|
|3. Proactive surveillance|
|Working in conjunction with the Duke Population Health Management Office, Cameron and his colleagues use sophisticated EHR record searches and risk prediction tools to find patients who need a certain treatment or referral. In particular, they focus on finding patients with late stage CKD, who may otherwise soon experience a traumatic and costly transition to dialysis.|
The CKD medical neighborhood project, which began in 2016 and is funded through 2017, has generated great interest across Duke. Specialists in endocrinology, geriatrics, and cardiology are looking to replicate the program so that they too can collaborate with PCPs in an effort to improve patient care, said Cameron.
Medical homes and neighborhoods still in early stages
Most U.S. hospital systems have not yet formalized the medical home or medical neighborhood concept, and patients routinely bear the brunt of a lack of collaboration. For example, patients are often unaware of who the “go-to” doctor to manage their illness is, and the PCP and specialist often do not know either.
In addition, many patients do not follow through with a written referral from the PCP, and those who do follow through are often deterred by long wait times to see the specialist.
“The current system is burdensome for patients,” said Cameron. “It makes them the intermediary; they have to manage their own care.”
Meanwhile, many referrals made to specialists are considered “over referrals,” meaning that PCPs will make a referral when “what’s needed are answers to simple questions,” said Cameron.
PCPs on board
Although still a pilot project at Duke, the CKD virtual medical neighborhood has been wholeheartedly embraced by Duke PCPs. “They tell me it’s the greatest thing since sliced bread,” said Cameron. Indeed, Cameron’s colleague, PCP Michele Casey, M.D., regional medical director for Duke Primary Care, echoes this.
“This program has had a significant positive impact on patient care. Providers often have what they consider ‘easy’ but important questions about a patient. Until now, they had no way to get help other than making a face-to-face referral.” Michele Casey MD
If it all sounds too good to be true, it sort of is – at least right now. “I don’t get paid for this,” said Cameron. The grant from the DIHI covers the costs of the program, but it is still unknown how the program will be funded in the future. “Our goal is to figure out the business model,” said Cameron.
Source Medical News TodayThe demise of the hospital dining room, Michael Kaye. CMAJ. 1996 Apr 15; 154(8): 1268–1269
Building a Virtual Medical Neighborhood for Chronic Kidney Disease in Duke Primary Care in Duke Institute for Health Innovation DIHI
Can technology transform chronic disease management? in Medical News Today
4 approaches to achieving digital maturity in Allscripts
Telemedicine Offers a Convenient but Narrow Window of Care in The Epoch Times
Digital doctors: how mobile apps are changing healthcare in The Telegraph
Better record sharing coming to Bend in The Bulletin
Moving from the “Medical Home” to the “Medical Neighborhood” to Better Serve Patients with Complex Needs in Institute for Healthcare Improvement
Why Innovation in Health Care Is So Hard in Harvard Business Review HBR