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Saturday, June 28, 2014

How best to communicate?

I had a very interesting conversation with colleagues tonight regarding optimizing communications within a health care network. It has always been a pet peeve of mine that communication networks among physicians tend to be very ad hoc in their functioning and information exchange. There was agreement within the group that something needed to be done. However, there was no consensus on exactly what optimal communication strategies should look like.

One of my colleagues who is an orthopedic surgeon, thought the best tool for his communication needs was the phone. It was his opinion that this approach afforded him with the fastest way to get the information he needed to ascertain whether he needed to see the patient or not and he was perfectly willing to use his time in a non-compensated fashion to avoid filling one of his new patient slots with a patient that would not feed his operative machine. For him, it seemed that the only reason to communicate with his fellow docs was to make sure that he did not interrupt the flow of good operative candidates into his office. There were merits in this communication approach in that it can address the concerns of primary care physicians and patients in real time and perhaps serves their immediate needs.

Still I have somewhat of a different perspective on the need for synchronous, real time communication, particularly by using the phone. When that encounter he describes is over, the only record of what was asked and what was said exists in various parties' minds. Presumably there was some sort of information shared with the consultant, some of which he heard, some of which he did not, and of the part he heard, there is some fraction of that he retained. In response, he made an assessment which was communicated to the consulting party, likely with a set a recommendations. What parts of the assessment and recommendations were heard and retained by the consulting physician shares the same limitations.

At some point, the assessment and recommendations get transmitted to some part of the medical record. I would venture to guess that at least part of this will be attributed to the physicians who gave his recommendations over the phone. How closely these track with what was said or intended is anyone's guess. Whether this note gets forwarded to the consultant is unlikely, meaning in some sense hearsay is documented in the medical record. Alternatively, nothing is recorded at all. It may be that none of this actually matters in that little or nothing was really at stake. Who really knows? We will never know since the record of this type of encounter and call will always be incomplete and error filled until we deploy software which records and parses everything we say and hear.

Am I being a nit picker about this? Is accurate communication important when dealing with someone's health? Imagine the legal system where a similar standard for communication was used? What is it about health care where we settle for spoken instructions and written records riddled with errors and imprecision?

I think this is part of a much larger issue regarding the best use of information to support decision making and coordination of care. Neither of these tasks are really priorities in the current world. Information collection is ad hoc. Decision making is very intuitive and system one based. In a world where there are few consistent feedback loops, any decision which is roughly equivalent in terms of financial outcomes becomes acceptable. Coordination of care is much talked about but also done in an ad hoc manner with no real rules of engagement. I talk to you and you talk to me. I think I hear what you tell me and you think that you hear what I tell you. I think I get what I want and you think you get what you want, and no one has any real idea of whether the patient gets what they need, unless their only priorities are to be dealt with quickly but not necessarily effectively. We prioritize speed and "efficiency" and that is what we get, nothing more and nothing less.

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