Continuity of care is the sharing, coordination, and integration of medical information among different providers to support patient care across multiple points in time and multiple care settings. This process is a vital component of patient care quality. According to some studies, up to 80% of serious medical errors relate to miscommunication during transitions of care between medical providers, leading to more adverse events, more hospital readmissions, more unnecessary duplication of care, and higher costs. As the incentives in the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010 drive the transition from volume-based to value-based medical care, highly effective continuity of care will be integral to the success of new primary care practice models such as the Patient Centered Medical Home and new reimbursement models such as Accountable Care Organizations.
Continuity of Care at Missouri Cancer Associates
I practice hematology and medical oncology in a community cancer center with nine medical oncologists and six radiation oncologists located in a mid-Missouri city with a population of 100,000. We admit our inpatients to a 400-bed secondary level community hospital. Both organizations have implemented electronic medical records (EMRs) and computerized provider order entry (CPOE). Within our practice, the very existence of the EMR provides excellent support for continuity of care. When we take night or weekend call or cover for a partner on vacation, we have rapid, highly reliable access to a complete medical record on any patient currently under the care of our group. The days of struggling with incomplete information because a paper chart was lost are long gone.
Coordinating our patients’ care with their primary care providers, with other specialty groups, with the hospital, and with organizations outside of our community is another matter entirely. Almost all of the physicians and hospitals in our area have implemented some type of EMR, but these systems come from a variety of vendors, and in practice all are completely incapable of exchanging information with each other, even though each is certified to have the ability to produce and transmit a Continuity of Care Document (CCD). When one of my patients is in the hospital, I have the capability and permissions to view his inpatient EMR. However, the only way to transfer inpatient data to my office EMR is to print it out on paper and scan it into my office system where it becomes an unsearchable PDF file with data that is not properly integrated into the rest of the record.
To compensate for this major gap in our EMR capability, we leverage the fact that our private practice physician community is relatively small, and almost all the practitioners know each other very well. When we request or provide consultations, admit or discharge patients or make major changes in care plans, we make a special effort to personally speak with the other physicians involved and keep the team coordinated. We have also developed a highly effective system to exchange clinical notes and laboratory reports between physician offices by fax. For the most part this results in very good continuity of care, but it depends on the diligence of individual doctors, and there are occasional lapses. In addition, there is an academic medical center with its own physician groups in our community. Patient care occurring in that system or outside of our community is opaque to us, and obtaining information about the care our patients receive in those settings is much more difficult than it should be.
Because IT and continuity of care are both essential components of a learning healthcare system in the 21st century, it seems reasonable that IT would develop the information exchange capabilities to support excellent continuity of care. Continuity of care should not depend on the actions of individual practitioners. The tools and procedures to support it should be built into the system. Unfortunately, progress in achieving effective health information exchange continues to lag. In addition to improving our technology, we also need to improve the science behind continuity of care, including translational research to design procedures and document templates that enable medical practices and healthcare organizations to implement high-quality continuity of care.
Continuity of Care Resources
The HIMSS Continuity of Care Task Force has been very active in this area, producing a continuity of care Guide for Ambulatory Practices and numerous continuity of care resources. The American College of Physicians (ACP) has been developing the concept of a Patient Centered Medical Home Neighborhood as a model of the interface between primary care and specialty/subspecialty practices, publishing a core position paper that summarizes the model and also resources for implementation. Finally, the Joint Commission’s Transitions of Care Portal is an excellent source of knowledge in this area, and I would highly recommend their two “Hot Topics” white papers: The Need for a More Effective Approach to Continuing Patient Care and The Need for Collaboration Across the Entire Care Continuum .
About the Contributor
David M. Schlossman, MD, PhD, FACP, MMI, has been a practicing physician for over 23 years—caring for patients with a wide variety of malignancies and blood diseases. He currently is an oncologist and informaticist for Missouri Cancer Associates.