Expanding your healthcare network

FigureOur healthcare system needs to change. It needs more than reform—it needs a transformation. Reforming the current system does not solve the problems inherent in the philosophy and the delivery of healthcare. The latest efforts to reform healthcare have laudable goals and ideology, but their implementation into the existing healthcare system is not creating the necessary changes of more efficient, effective, and patient-centered care. These reforms often focus on the financial incentives for meeting the requirements, measuring parameters, and establishing care programs. The reforms are sometimes so focused on meeting parameters that patients' needs, goals, and values are left out. Relationship of hope In a previous column, I wrote about a key concept I believe is essential for healthcare transformation: building a “relationship of hope” with patients.1 Healthcare needs to be more than patients seeing a clinician. A relationship is built when the patient sees the same clinician at the majority of his or her visits so the clinician knows the patient, the patient's values, needs, situations, and goals. I believe another key concept in transforming healthcare is building a network within the healthcare community by developing relationships with the clinicians that are involved in a patient's care. Our current healthcare players often work in near isolation, each doing their own job. Radiology or consult reports may be shared between a consultant and clinician (or between a radiologist and a clinician, for example), but actual dialogue or two-way communication between clinicians is rare. There is more dialogue and interaction between contractors building a house than there is between the various players in the healthcare system. Everyone is an expert in what they do, but without coordination, the care becomes suboptimal, inefficient, and expensive. Imagine a house being built where the plumbers, carpenters, electricians, painters, cabinetmakers, and even the architect and general contractor do not converse except for an occasional letter to the general contractor about what task they have completed. The house could easily turn out a mess without the meticulous coordination and two-way dialogue between the contractors. Our health and our lives are more important than a house, but the delivery of healthcare does not come near the networking and coordination of care that is put into building a house. The benefits of networking Consider some examples of how clinicians could better network and communicate to more efficiently and effectively deliver quality care. A 68-year-old male patient of mine was seen in the ED and had a chest X-ray (CXR) done due to shortness of breath. The X-ray report I received noted “nodularity” in his right lung and suggested a computed tomography (CT) scan of the lungs to clarify the issue. The easy thing to do would be to order a CT scan as suggested by the radiologist. Instead, I placed a call to the radiologist. He reviewed the X-ray image while we talked and was not extremely concerned with the nodular findings, suggesting an alternative of a repeat CXR in 2 months. I discussed this information and option with the patient who preferred a repeat CXR in 2 months. The follow up X-ray showed stable, chronic findings and did not need further followup. As a result, the patient avoided the radiation exposure from the CT scan of the chest, did not have to spend time going for a CT scan, and the system paid for a CXR instead of a chest CT scan.2 Networking with a 5-minute phone call to a radiologist made a difference in the care of this patient, providing more information so the patient could make a choice. Engaging the patient Another example involves a 45-year-old male patient who had an audiology exam for hearing loss. The exam showed unilateral sensorineural hearing loss. The audiologist was concerned about an acoustic neuroma and told him he should get a referral to see an otolaryngologist. The easy response would be to simply make a referral to the otolaryngologist. Instead, I made a phone call to the otolaryngologist, and we discussed the rare possibility of acoustic neuroma. He shared with me that 80% of the time surgery for a benign lesion (should that be the cause) results in hearing loss anyway. Rather than an otolaryngologist consult or an MRI to evaluate for an acoustic neuroma, he suggested a repeat audiology exam in a year to assess for progression. I discussed this with the patient who chose to do a follow-up audiology exam in a year. The patient was pleased with this solution, saving him the time of going to an otolaryngologist (and possibly an MRI exam) as well as the associated costs (to him and his insurance company). This process engaged the patient in making a choice of two alternatives based on the consultant's information. From isolation to coordination Another patient of mine was seeing a pulmonologist for some lung issues and a urologist for a renal mass. Each consultant was following up every 6 months with a CT scan; one scanning the abdomen and pelvis, the other the chest. Neither knew the patient was seeing the other consultant and having regular CT scans. Over 18 months, this patient had 5 CT scans of the chest or abdomen. I was concerned about the amount of radiation he was receiving, so I contacted each consultant as well as the patient. This resulted in the consultants using fewer CT scans to follow the conditions and more X-rays or ultrasounds, which lessened the patient's exposure to radiation. The issue was not that all CT scans had to be eliminated but that there was an awareness of what others were doing and the cumulative radiation exposure that, in itself, could harm the patient. Treatment became coordinated, instead of three separate players providing care independently. Bringing care together Our patients often see many different clinicians for various problems. The challenge is the gastroenterologist does not talk with the pulmonologist, who may not even know there is also an orthopedist or dermatologist working with the patient for other various conditions as well. Each consultant is working with a narrow focus, in a particular field, unaware of what the primary care clinician is doing, let alone the other consultants. I frequently call consultants to discuss care, especially in light of the particular goals and values of a patient I have known for years. Consultants usually send office notes to us after a visit, but this is not dialogue—it is one-way communication. I will often copy my patient's primary care visit note to the consultant so he or she can see what has been done and what diagnostics have been ordered. I may even include questions about treatment changes or questions the patient had. By establishing dialogue, we develop a relationship and can give the patient better care. Reimbursement's role What prevents this kind of networking from occurring in our current system? First, our current system does not pay for this networking. Reimbursement is based on the number of patients seen, not on building and using the healthcare team's network to give better care. We are not compensated for making phone calls, gathering information, and building networks. We can order whatever lab test, referral, or diagnostic test we want to order, even if there may be a better or more appropriate way. There is little incentive to involve the patient in the decision-making process. Avoiding inappropriate testing through networking and communication has not been a priority. In fact, we usually are not even aware that what is ordered might be inappropriate or might not be the best choice. We do it because we think it is needed. Second, we often do not have well-developed networks and/or relationships with radiologists, pathologists, and other consultants. We may read their notes and reports, know their names, and, occasionally, call with a question, but we often do not really know these consultants, and we may find them hard to reach. Some may not want to spend time talking on the phone when they could be seeing patients or doing procedures. It comes back to reimbursement. Fortunately, many do like to talk. I have had consultants spend 20 minutes with me on the phone answering my questions and teaching me more about the specific conditions. Building the network What I propose is not a matter of ordering less or doing less but ordering the most appropriate, useful diagnostic test or treatment. The goal is the right treatment rather than overtreatment or undertreatment. This involves communicating, networking, building relationships with other clinicians, working together to integrate knowledge, and planning for the care of a patient. This may involve a call to a pathologist at the lab to discuss the meaning of a biopsy result or talking with a pathologist about which lab test might be most useful in working up a patient with a specific condition. Pathologists are available and, I find, willing and eager to talk about clinical cases and to help make choices about diagnostic testing. For example, what is the difference in a clinical utility between an antibody test versus a polymerase chain reaction test for Lyme disease? A pathologist at your reference lab can help you with this and other questions when working up a case. Radiologists can be very useful when working up a condition, helping you to decide what the most useful diagnostic test for the patient is. Will an MRI, CT scan, or ultrasound best tell me what I want to know? Talking to the radiologist after the test is completed and having him or her view the image while you share more clinical information can help determine what is going on with the patient as well as how to proceed. Build the network of care for your patient, and care will improve. This networking will make the care you provide more appropriate, efficient, and cost effective. Over the years of building networks of care, I have developed relationships and even friendships with many other clinicians. We do not just know each other's names, we know each other as individuals—as clinicians. As a result of these relationships, many have given me their direct phone lines, pager numbers, cell phone numbers, or e-mail addresses. They know me and know I want to be involved. My patients appreciate this coordinated network as well. They feel reassured knowing that I am in touch with their other clinicians. Transforming healthcare One of the problems with our current healthcare system is that it does not promote or provide incentive for this kind of care. Our reimbursement system pays for what is done, whether it is the best care or not. It pays for what we do, and is not even aware of what was not done or avoided. I receive no reimbursement for making these phone calls, for avoiding unnecessary care, diagnostics, referrals, and providing more appropriate and efficient care while saving money on healthcare costs. Some see the solution is to add another person to the network to make these phone calls in order to free up the clinician to see more patients. The point is the clinician needs to be making these contacts and is the person most familiar with the patient. Transformation of healthcare must see the need and importance of clinicians using initiative and taking time to consult and dialogue with other clinicians to both share information and to determine the most appropriate care for the individual patient. The value of clinicians making these calls, developing these relationships, and expanding the network of care must be recognized and reimbursed. Networking can make a financial difference as well. A couple of years ago, I began tracking the time I spent outside of an office visit making phone calls, like the ones I shared above, networking with other clinicians about patient care. I tracked time spent making phone calls along with conservative estimates of dollars saved in diagnostic testing and referrals because of the call. The average amount of money saved per hour of time on the phone was just over $2,300 per hour. The 30 hours I have spent on the phone have saved over $70,000. This money is not saved for my clinic and often not for the patient (though the patient often saves copays as well as time). The savings primarily benefit the third-party payer who has no idea how much has been saved by this unreimbursed networking and communications. Money not spent, unnecessary testing not done, or referrals avoided are difficult to track. Centering on the patient Our healthcare system desperately needs transformation. We are not efficiently and effectively providing healthcare that utilizes all of the resources at hand while eliciting the patients' values, preferences, and priorities. Attempts at reform, though often good on paper, are still focusing on paying for certain things, for following proscribed practices and measures, rather than encouraging networking and innovation of the care process. Some plans add more team members to coordinate care to give clinicians more time to see patients, but the clinicians need to be doing the coordinating, the networking, and spending more time with patients by involving them in the process. We need to transform the process, not with the goal of clinicians seeing more patients, but seeing the value of clinicians spending more time with patients and communicating with those involved in the patient's care. When the patient is our motivation, building relationships with the patient and the network of people involved in the care—not on money—we will see less expensive, more efficient, more effective, and more patient-centered health and caring.

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