Published in the December 2018 issue of Today’s Hospitalist
WHEN IT COMES TO ordering consults and getting consultant recommendations back, hospitalist Ann Kellogg, DO, points to this built-in safeguard at the 120-bed Sky Lakes Medical Center in Klamath Falls, Ore., where she works: Direct doctor-to-doctor communication about consults has long been mandated by the medical staff bylaws. That direct communication, she notes, ensures that hospitalists can have any questions they may have about a consultant’s proposed plan of care answered.
But that mandate doesn’t mean that consultant communications always run smoothly. “We call it ‘the drift-off,’ ” says Dr. Kellogg, who is assistant director of the hospitalist service. “Specialists consult and then they disappear, even if the issue isn’t resolved.” That leaves hospitalists trying to catch up with subspecialists to have them explain what they need for discharge or to see if a patient can be followed up as an outpatient. “We know the consultant has seen the patient, but the note doesn’t exist.”
Ordering consults isn’t just a problem in community hospitals; if anything, hospitalists in academic centers complain even louder about the resident-based paging systems they use to order consults, ones that leave them sitting around waiting for callbacks (and for consultants’ recommendations). Hospitalists in both academic and community centers point out that the way they order specialty consults and receive recommendations can waste time and drag down the momentum behind patient care. That’s the case whether the ordering system requires paging specialists or placing consult orders directly in the EHR.
“We have to handle things with kid gloves because we need to keep consultants happy.”
~ Ann Kellogg, DO
Sky Lakes Medical Center
And even when hospitalists can place electronic orders, they often struggle to find the right balance between relying on the EHR alone and backing those orders up (or even replacing them) with some form of direct communication, via a phone call, a text message or an in-person discussion.
Indirect vs. direct communication
In academic centers where traditional resident-directed, pager-based consult communication still lives on, hospitalists say they’re having a hard time pushing subspecialists to move at least to electronic consult orders. But in many hospitals, EHR-based consult ordering is replacing paging.
As for placing electronic orders vs. picking up the phone, there are plenty of theories but little evidence about whether indirect consult communication ultimately adds to or takes away from efficiency of care and patient outcomes.
What is clear is that in-person communication with consultants is becoming less common. One factor driving the push toward electronic orders in teaching hospitals—where residents and fellows typically are the first to respond to those orders—is that academic centers want to streamline trainees’ work to comply with resident duty-hour rules.
Some sources also believe that “indirect” is the millennial generation’s preferred approach to communication. A study published in May by the Journal of Hospital Medicine reported these findings: While hospitalists preferred direct communication with consulting services, 91% of hospitalists across four U.S. academic hospitals said that in-person communication occurred in fewer than half of all consultations.
At the same time, local hospital culture plays a big role. Dr. Kellogg in Oregon, for instance, has learned to not be shy about chasing down consultants—something younger, inexperienced hospitalists often have trouble doing.
But she can’t be overly demanding toward consultants either. “We have to handle things with kid gloves because we need to keep consultants happy,” she notes, adding that in rural environments like her own, recruiting a new specialist costs a lot of time, effort and money.
“A huge rate-limiting step in our daily workflow is waiting for consultant re-commendations.”
~ Chirag R. Patel, DO
Ohio State Wexner Medical Center
“I have their cell phone numbers and I hunt them down,” says Dr. Kellogg, “but it’s a dance.”
“Ninja” consult notes
By comparison, just finding the right consultant at a giant academic center can be a challenge. Since Johns Hopkins Hospital in Baltimore switched a few years ago from a paging system to ordering consults through its Epic EMR, adult and pediatric hospitalist Amit K. Pahwa, MD, says he often doesn’t even know which consultant to call if he needs to clarify his questions or track down a missing or delayed note.
“I put the order in Epic, but I don’t know who gets that order most of the time,” Dr. Pahwa says. “All of a sudden, I will have this ninja consult note on a patient that I didn’t even know happened.” Or he finds out from a patient that a specialist came by and has ordered a procedure for the next day. And because doctors can access the EHR from anywhere, including their homes, consultants won’t “drop the note in the chart until sometimes 10 or 11 p.m.” That can delay a hospitalist’s care plan by hours or even days.
What would be helpful instead, he says, would be changing the hospital’s culture so that consultants “shoot a quick text or page back” to the requesting physician “saying, ‘I got the order and this is when I plan to see the patient.’ That way, you would at least know who the person is seeing your patient and get back to him or her if you had to.”
What works much better in academic centers, sources say, is moving to a specialty consult service that does just that: consults full time, instead of trying to squeeze them in at the end of subspecialists’ workday or around their clinic and office visits. Even when such services work off electronic orders, the specialists and the advanced practice providers who often staff those services are onsite and always around, giving hospitalists a chance to get to know them (unlike rotating residents) and to talk to them about specific patients.
But as far as he knows, Dr. Pahwa adds, there is no effort underway at Johns Hopkins to change how consultants communicate.
According to Dr. Pahwa, some evidence drawn from outpatient settings indicates that poor communication “leads to poorer outcomes” and that “EMRs don’t necessarily keep everybody on the same page.” Further, he says, “nuance gets lost in electronic communication vs. in verbal-to-verbal communication.”
“I put the order in Epic, but I don’t know who gets that order most of the time.”
~ Amit K. Pahwa, MD
Johns Hopkins Hospital
The value of direct communication with consultants is being borne out in preliminary research being done by Chirag R. Patel, DO, associate division director for hospital medicine at the Ohio State Wexner Medical Center in Columbus. One big plus, says Dr. Patel: Direct communication results in faster recommendations, which are then “more likely to be implemented the same calendar day.”
“A huge rate-limiting step in our daily workflow is waiting for consultant recommendations,” says Dr. Patel. That’s led him to study the impact of both direct and indirect communication on turnaround time. While his first study is still under manuscript review, he says there is “benefit to how quickly we can get recommendations back if we go ahead and contact the consultant directly after placing an order in the computer.”
Moreover, he adds, “If I go ahead and make a phone call, consultants will typically return the favor by calling me back after seeing the patient and formulating their recommendation.”
Dr. Patel also thinks that hospitalist-consultant communication could be improved with better use of technology. Service-specific wireless phones carried by all hospital providers, for example, could do away with the need for doctors to sit by landlines in hospitals waiting for consultants to respond to pages. Also, secure, HIPAA-compliant two-way mobile messaging through programs like DocHalo or Epic’s mobile messaging app allows doctors to have closed-loop text conversation with their colleagues. He has found secure messaging to be a timely, efficient way to share information—benefits that have led to “ever-increasing buy-in of the technology.”
Set the example
At Miami’s Baptist Hospital and West Kendall Baptist Hospital, chief of hospital medicine Andres F. Soto, MD, MBA, similarly thinks hospitalists who want faster communication with consultants should take the lead and set an example of the behavior they want reciprocated. They can start, Dr. Soto says, by making themselves more accessible to consultants. To that end, his group this fall has piloted the use of two dedicated phone numbers (one for each of the two hospitals they work in) that consultants can call to reach them.
“We removed the barrier of having to look up my phone number or the patient’s room number. All they have to remember to reach a hospitalist is ‘222,’ ” something the hospitalist group advertised widely to the medical staff before putting it in place. When consultants call 6222 in one hospital, 7222 in the other, they reach the hospitalists’ answering service, which then automatically directs callers to the right hospitalist.
“We want people to call with recommendations rather than just put a note in. We want that to be the culture.”
~ Elizabeth Schulwolf, MD
Loyola University Medical Center
“We complain about why we don’t talk to each other and communicate better,” says Dr. Soto. “Part of the reason is that we don’t make it easy for doctors to do that. For us, I think a single number is the way to go.”
In his hospital, Dr. Soto explains, hospitalists order consults through the EHR. But he also encourages group members to follow up on these indirect orders with a direct call to the consultant because “that phone call will usually save you a lot of time.” He admits that directive sometimes goes unheard. “With the ever-changing landscape in hospitals, it’s hard to get physicians to talk to each other.” Unfortunately, he adds, “most consults are not physician-to-physician, due to many factors including busy schedules and a variety of communication styles that can vary among generations.”
Handling non-urgent consults
That’s not to say that indirect communication with consultants through an EHR hasn’t sometimes been a godsend for hospitalists. When the gastroenterologists at Loyola University Medical Center in Maywood, Ill., recently began an online consult ordering process, the hospitalists applauded.
That online process makes routine, non-urgent GI consults, particularly when those are needed the following day for patients admitted after hours, go much more smoothly, says Elizabeth Schulwolf, MD, director of the 37-provider hospital medicine division there. “They can always call you if they have a question,” says Dr. Schulwolf, “but it has made me more efficient because I am not waiting to hear back from the person who I paged.”
In return, she says, the GI consultants have been “good at getting some sort of direct communication back—usually a secure text or direct page—with their recommendations.” (Orders for urgent consults are likewise made through the EHR, but hospitalists must also call the GI service to follow up their electronic order.)
Motivated by concerns that pager calls for non-urgent consults at night are affecting resident work hour rules, Dr. Schulwolf is now talking with other services about setting up similar systems. Not all consults are equal, she says. “Say you just admitted a person who is on dialysis at home. You have to call the fellow on the dialysis service to ask for that—but what if you could just put the consult order in? This is easily something that shouldn’t require a call overnight.”
But Dr. Schulwolf also wants to make sure the online ordering system doesn’t do away with one-on-one conversations about consultations. “We want people to call with recommendations rather than just put a note in,” she says. “We want that to be the culture, and we want to emphasize that we value the conversation.”
And if consultants are slow to respond, says Dr. Soto, hospitalists “need to take the initiative” and call. “At the end of the day, we are responsible for patient outcomes,” he points out. “We are the ones overseeing a patient’s overall plan of care, so we need to call and say, ‘I think Ms. Smith is ready to be discharged. Do you agree?’ ”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Are consults being overused?
IN MIAMI, some of the subspecialists at Baptist Hospital voiced concerns that the hospitalists were requesting too many consults. Whether or not that feedback had merit—and no evidence exists to indicate those concerns were accurate—the hospitalists decided to face the issue head-on.
As of last year, to be eligible to share in the productivity component of their incentive plan, the hospitalists must have documented the reason they needed to order consults for their patients at least 80% of the time.
“It’s a one-liner in the order to give us an idea of why the consultation is being ordered,” explains Andres F. Soto, MD, MBA, chief of hospital medicine at Baptist Health Medical Group. “We are internal medicine doctors, so we should be able to treat most pneumonias and tachycardias. What is the reason why this case goes beyond your scope?”
Part of the problem when someone suggests there have been too many consults, he adds, is that “we have no metric or national benchmark to compare ourselves to.” By instituting the incentive, the group will be able to track how many consults take place each year, then use those data to optimize consult utilization. (Because their fiscal year just ended, Dr. Soto still doesn’t know whether group members met their target.) He also points out that by putting this action plan in place, the hospitalists are letting hospital administration know they take such concerns seriously.