Improved interspecialty communication enhances care

National report - Effective communication between medical specialists is necessary to ensure that all patients receive proper care. But the recent healthcare reform, combined with insurance cost issues, oftentimes results in dermatologic patients seeking care at emergency rooms or primary care facilities. It is the responsibility of physicians of all specialties to meet this challenge and improve interspecialty communications for the benefit of all patients.

Because of decreased physician availability, rising healthcare costs and incomplete insurance coverage, dermatologic patients may not always be able to see a dermatologist. As a result, patients may receive sub-optimal dermatologic care from nondermatologists working in primary care facilities.

“Dermatologic patients are often seen by emergency room physicians who may or may not be familiar with the nuances of dermatologic disease and the seemingly endless list of differential diagnoses,” says Norman Levine, M.D., a dermatologist in private practice in Tucson, Ariz. “A dermatosis can easily be misdiagnosed by the nonspecialist, which can quickly lead to inappropriate therapy.”

Moreover, depending on demographic location, getting an appointment with a dermatologist can be difficult, and some patients may not want to wait several weeks to have a suspicious cutaneous lesion examined.

“The diagnosis and treatments that have been initiated in dermatologic patients by ER physicians are often erroneous. Therefore, it takes a lot longer to get to the heart of the matter and then reverse and treat them appropriately to get the proper therapeutic results. This is a growing problem which must be met head-on with an improved coordination of communication between specialties,” says Helen M. Torok, M.D., a dermatologist and medical director at Trillium Creek Dermatology in Medina, Ohio.

Derms on call
In a perfect world, the emergency room physician would be able to contact and consult with an on-call dermatologist who would offer expertise concerning a challenging dermatologic case. However, not all medical communities and healthcare facilities offer this option, and, according to Dr. Levine, this is one facet of healthcare that could use a great deal of improvement.

When in doubt, an ER physician often erroneously treats a patient’s non-descript rash as a fungal infection. Oftentimes, the ER physician will prescribe inexpensive and harmless treatments, but the patient’s condition will likely not improve, perpetuating a spiral of ineffective primary care. This is a typical scenario in which the ER doctor should be able to phone an on-call dermatologist and ask for advice as needed, Dr. Levine says.

“In the best of circumstances, there would be a panel of dermatologists in the community who would rotate calls just like any other specialty does in the ER and would be willing to field phone calls on their own time from ER doctors,” Dr. Levine says. “That kind of cooperation and coordination would be ideal for the patient, because it saves them time, effort and expense of visiting multiple physicians.”

Just as many dermatologists enjoy privileges in hospitals, there should be a ready-made panel of dermatologists in place as a condition of these hospital privileges. Dr. Torok is one of many dermatologists who recognize this growing problem, so she always makes time for ER physicians who call for advice concerning challenging dermatologic cases.

“The more I educate ER doctors, the better the patient has a base of treatment paradigm. Patients will have a better set of treatment plans so that when they get to me, hopefully they will already be on the road to recovery,” Dr. Torok says.

Argument of inconvenience
Many dermatologists may not like to deal with the ER or go to the hospital for consults, because it may interrupt the flow of their private practice. Nevertheless, the treatment and management of dermatologic patients who visit emergency rooms must be improved for the benefit of patients as well as eradication of difficult issues that have been raised by the current healthcare reform.

As the new healthcare reform takes effect, millions of Americans without insurance supposedly will have access to dermatologists. However, according to Dr. Torok, there will be limited room for them, and patients will still need to go to walk-in clinics and ERs if they need to be seen immediately.

“Primary care facilities will be the front line for millions of patients with a dermatologic problem, and ER physicians need to both be better versed in dermatologic symptoms and have an increased access to dermatologists for advice,” Dr. Torok says. “This is one way to bear the brunt of the healthcare reform and significantly improve patient care.”

A bigger problem
According to one dermatologist, the growing communication rift between dermatologists and other specialties involves much more than ER physicians.

“Years ago, when I saw dermatologic patients referred to me from the ER, they would bring along a handwritten note or letter from the ER physician stating what was done, what tests were performed, the suspected clinical diagnosis and what treatment was given. Today, only a very small fraction of these patients referred to me have such a report,” says Robert T. Brodell, M.D., a dermatologist in private practice in Warren, Ohio.

This drop in communication is likely due to the fact that ER physicians are overworked and overregulated, and there simply is not enough time to produce detailed patient reports. According to Dr. Brodell, referred patients often need to recount which exams were performed in the ER and what their results were. Much of this information can get lost in translation, particularly in the older population.

More and more ERs are gravitating toward an electronic medical record system, but this can add to the confusion. Patient files are often 20 to 25 pages long, and according to Dr. Brodell, reports are full of generic items that are seemingly generated automatically from the software.

“If the physician did not override the system, the items in these reports are very likely automatically generated. This makes me unsure if the scores of questions and exams listed were actually asked or carried out, or if the ER doctor was even on target with the diagnosis in the first place,” Dr. Brodell says.

Coding conundrum
Adding insult to injury, the diagnosis is based on codes, Dr. Brodell says. If the ER physician suspects vasculitis as the diagnosis, the report will generically list an all-inclusive code number for vasculitis. This is far from specific, as there are many different kinds of vasculitis, adding to the ambiguity and counter-productivity of the patient report.

“This poses a great problem, especially in dermatology, where there are no specific codes for a lot of things we diagnose. After sifting through pages and pages of unintelligible bureaucratic jibberish, I may finally get to the end of the note and have learned very little in regards to why the patient is in my office and what the problem is,” Dr. Brodell says.

“The impersonality of the new electronic system creates an even bigger communication rift between dermatologists and other physicians such as those in the ER,” he adds.

Dr. Brodell says the government (with some push from the American Medical Association and the American Academy of Dermatology) needs to simplify the requirements for electronic systems and that patient visits should be divided into low, medium and high priority, instead of the current five-level system. This will help make the electronic patient record equally transparent for all physicians reading it and keep it concentrated to medically-relevant, necessary and useful information with regard to the patient and the medical condition at hand.

“I believe that the new electronic medical record system is many steps backwards from a much-needed improved communication between dermatologists and other physicians, something that is already lacking,” Dr. Brodell says.

Dermatology is a visual field, and it can be very challenging for physicians of another specialty to understand the complexities of dermatologic nomenclature and the nuances of the clinical symptoms of various dermatoses.

“If we can slowly and patiently try to guide ER physicians through our complex nomenclature and panel of symptoms for a given dermatosis, not only will patients benefit, but all physicians involved in the process, as well,” Dr. Torok says.

Disclosures: Drs. Brodell, Levine and Torok report no relevant financial interests.