Monico Peter Baňez, MD, MBA, FACP, SFHM
CHAPTER CONTENTS
Progressively fewer neurologists embrace the traditional model of combined outpatient and inpatient care, and this has introduced difficulties with continuity of care. Not only do patients generally want to see the same providers, but many providers may feel that they are left out of the loop if communication is not optimal. Lack of continuity presents greater opportunities for medical errors, such as late-resulting labs being overlooked or planned medication adjustments not being made.
These difficulties are not insurmountable. Most electronic medical record (EMR) systems have the capability of secure messaging to facilitate secure transfer of information and notification of events. Also, Health information Exchanges (HIE) are becoming more robust, aiding communication between enterprises.
However, no technical solution can replace the personal touch. An increasing number of EMRs will notify primary care providers (PCP) if one of their patients has been hospitalized. A brief visit by the PCP can make a major difference for the concerned patient whose life is in the hands of strangers. As hospital neurologists, we should help maintain continuity of care and help PCPs maintain their connections with their patients.
CONTINUITY OF CARE
Hospital Admission
Unless the inpatient and outpatient medical records are in a single database and accessed using a single EMR, the hospital provider does not have easy access to outpatient records. When an admission occurs after normal business hours, manual access of office records is frequently impossible. The best answer for this is an HIE, but these systems are not operational in many markets. One-off connections can be accomplished between EMRs, but this is a huge undertaking for the Information Systems (IS) staff and does not always function smoothly. IS can provide web access in the hospital to select office EMRs. Until a local exchange is functioning, this may be the best solution.
Most PCPs want to know when their patients have been admitted. Communication orders can be built into most EMRs to make this notification automatic.
Hospital Discharge
Post-discharge care: Most patients admitted to the hospital need post-discharge care. One challenge can be finding a provider for this care, both neurologic and medical. Absence of health insurance makes this even more of a challenge. One option is to have community physicians and midlevel providers of both general medicine and specialties aligned with the hospital.
Study follow-up: Studies resulting after discharge have to be reviewed. Almost all systems have the capability of messaging post-discharge results to a provider’s inbox. Another technique that is particularly useful is to deliver a message to the provider when the results of all pending studies are complete, thus prompting review of the EMR. However the hospital physician is still responsible for follow-up on these data.
Medication reconciliation assures that specific neurologic meds are considered in the context of other prescribed meds.
Compliance continues to be a problem: One report found that 80% of patients are taking discharge meds after their first stroke, but only 60% after a second stroke. It is hoped that prompt follow-up to address provider and patient lapses will help.1
Follow-up appointments for discharged patients depend on the specifics, but, generally, we recommend follow-up at 2 weeks for stroke and transient ischemic attack (TIA), acute and subacute neuromuscular disorders, and seizures. Follow-up at 4 weeks is appropriate for patients seen in the hospital for nonurgent conditions (e.g., dementia, chronic movement disorder).
WHEN OUTPATIENT NEUROLOGY BECOMES INPATIENT
There will be instances when a patient seen in the clinic needs admission either urgently or electively.
Rapid workup needed: Patients with acute or subacute neurological problems may be worked into the clinic when admission is actually necessary. Although same-day diagnostics can sometimes be obtained, action on critical findings or stabilization of the patient can necessitate admission (e.g., mental status change with fever, multiple seizures, recent focal deficit).
Rapid treatment needed: Patients with conditions such a status migraine or myasthenia exacerbation often need admission to facilitate prompt treatment.
Deterioration with chronic disease: Patients with severe dementia or movement disorders are often admitted for aspiration or other complication of their disease.
WHEN A POTENTIAL INPATIENT BECOMES AN OUTPATIENT
The hospital neurologist spends significant time in the ED evaluating patients to be admitted and arranging outpatient care for those who do not need admission. Of the latter, there are those who can receive neurology consultation in the ED and then be discharged to PCP care, and there are those who need further neurologic follow-up after the ED consultation. In addition, there are a few who can have their complete evaluation performed in the office, especially if the system is conducive to urgent workup. Some scenarios that can be so treated include select patients with seizure(s), subacute onset of weakness, TIA, and headache.
All patients who are seen in the ED and discharged to home or clinic should be advised of clinical events that make return to the ED appropriate.
