Coordination of Care

For most people, one doctor isn't enough. If you ever move to a different city, get sick during a vacation, or develop a condition that requires specialized help, you'll eventually find yourself in an unfamiliar waiting room. Think of each new doctor as a new ally, another person who is committed to your health. Now the bad news: The larger your healthcare team, the greater the opportunity for misunderstanding, miscommunication, and mistakes.

Ideally, all the doctors on your team will work closely together. If one doctor prescribes a drug, runs a test, or makes a diagnosis, the others will know about it. Doctors call this "coordination of care." In the real world, however, the coordination can break down.

Uncoordinated care

A recent survey of 750 adults with health problems in the United States, Canada, England, Australia, and New Zealand uncovered worldwide shortcomings in coordination of care. As reported in the journal Health Affairs, roughly two-thirds of all the patients had seen three or more physicians in the previous two years, and these patients had plenty of complaints. Among the most common gripes: Different doctors often ordered the same tests; doctors often gave conflicting advice or information; and doctors didn't always share records promptly. In addition, patients who saw multiple doctors were twice as likely to fall victim to a medication error or other medical mistake.

Communication is the key

How can patients protect themselves? In most cases, communication is the best defense against misunderstandings and mistakes, says Mark Graber, MD,senior fellow at RTI International and professor emeritus of medicine at the State University of New York at Stony Brook. Patients should be able to clearly explain their condition and their current treatments to every doctor they see. They should also give all of their doctors a list of every medication they are taking.

But not all patients are up to the task, Graber says. "The sicker you are, the more trouble you will have communicating effectively," he says. "It can be extremely helpful to have someone with you who can listen to the doctor and ask questions."

A close call

Joanne Holland, MD, an internist at Northpoint VA Medical Center in New York, saw firsthand how a concerned loved one can help prevent disaster. One of her longtime patients faced an array of medical problems, including blood clots in his legs and mild dementia. He wasn't mentally sharp enough to keep track of his own medical care, but he had a very committed wife who took careful notes during every doctor's visit.

One day, the man visited a local doctor for treatment for a cold. During the visit, he also complained about pain that appeared related to a possible blood clot in his legs. Unaware that the patient was already taking the blood thinner warfarin (Coumadin), the doctor prescribed clopidogrel (Plavix), another blood thinner. The combination could have been deadly, but the patient's wife asked the right questions and prevented the mix-up. "It's a very glaring demonstration of the potential consequences," Holland says.

Health professionals know they have to improve their teamwork. In a recent report, the National Institute of Medicine listed care coordination as one of 20 top priorities for change in our healthcare system. The report noted that about 60 million Americans live with more than one chronic condition, such as hypertension and diabetes. To effectively treat these multiple chronic conditions, the report concluded, the clinicians and institutions serving each patient needed to actively communicate and collaborate.

Catholic Health East, one of the nation's largest healthcare systems, recently identified coordination of care as its most important issue for improving patient satisfaction. As reported in the Journal for Healthcare Quality, Catholic Health East now tries to ensure that all patients have a point person who can answer questions, offer advice, and pass along important information to other physicians. Physicians are encouraged to communicate frequently with each other, as well as with their patients. Most important, all physicians who treat a given patient are expected to be aware of the patient's overall care plan.

Committed doctors and nurses everywhere will do their best to improve coordination of care. Still, mistakes will happen. A crucial phone call won't get made, an x-ray won't get delivered. Remember, you're the most important member of your health team. By understanding your condition, asking questions, and speaking out, you can help put your doctors where they belong: on the same page.

Further Resources

Institute for Health Improvement
http://www.ihi.org 

The IHI offers resources and services to help health care organizations make long-lasting improvement "that enhance clinical outcomes and reduce costs." It also offers many reports of interest to consumers on patient satisfaction and safety.

Agency for Healthcare Research and Quality
http://www.ahrq.gov

The AHRQ offers factsheets, reports, and videos on patient safety and improving medical errors.

References

Interview with Mark Graber, MD, chief of medicine at the Veteran's Administration Hospital in Northport, New York.

Interview with Joanne Holland, MD, assistant chief of medical services at the Veteran's Administration Hospital in Northport, New York.

Blendon, RJ et al. Common concerns amid diverse systems: Health care experiences in five countries. Health Affairs. 22(3): 106-121.

Carroll-Solomon, PA et al. Improving coordination of care in long-term care--through residents' eyes. Journal for Healthcare Quality. 25(2): 30-37.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press.

Officials should target 20 key areas to transform health care system. Institute of Medicine. The National Academies. http://www4.nas.edu/news.nsf/isbn/0309085438?OpenDocument

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