In The Chaos Of Modern Medicine, Coordination Of Care Is Critical

David F. Torchiana, M.D., Chairman and CEO of the Massachusetts General Physicians Organization, says without a coordinated effort by providers, vulnerable patients are left feeling anxious and confused:

Fifty years ago it was routine for a physician practicing alone to manage patient problems by relying on memory and a paper record. Medicine didn’t require a full orchestra of providers. In most cases, a “soloist” could easily find and play the correct tune. That was all that was needed. Just about everyone liked this approach; patients developed a relationship with their doctor and trusted them to provide the right care.

The practice of medicine has changed. There is so much more to know and because we have more ways to diagnose and treat illness, optimum medical practice today requires many more players. Consider this point, made by my colleagues Tom Lee, MD and James Mongan, MD in their new book, Chaos and Organization in Health Care: in 2007 the number of new scholarly articles listed in the US National Library of Medicine’s database was twice what it was in 1996.

Just as when playing music, there is a difference between an orchestra and a group of isolated soloists. The pleasing sounds of an orchestra are the result of teamwork, coordination and orchestration to get things right. Unfortunately medical practice has not kept up with the evolution of the knowledge base – most physicians still practice in a solo or small group setting and even when they are aggregated together, typically there is inadequate attention, and insufficient resources, devoted to coordination.

Failure to coordinate and provide continuity of care undermines the patient and family’s faith in the competence of the team providing care. It also can result in harm. A hospitalized patient who hears multiple different versions of their treatment plan or worse still, no treatment plan at all, is left confused and anxious.

Uncertainty and insecurity are already part of being sick, poor communication compounds these fears. Patients want to know that information about their history and current care is shared among all providers, that those providers have a consistent and coherent approach to managing their care and that they can trust their providers because a relationship has developed with them over time.

Jeannie Haggerty at the University of Montreal has described these three types of continuity as informational, management and relationship continuity.

Electronic health records are helping to address the need for information continuity but assuring management and relationship continuity for patients is a growing challenge. These aspects of continuity are especially important in serious, life threatening illness or for a patient with multiple chronic diseases. By definition, a cancer patient, or one with heart disease, depression and pulmonary issues, is complicated. It usually takes multiple providers to deliver the right package of services and it is very important for those providers to communicate clearly and consistently with each other and the patient. A computer cannot provide this kind of continuity.

Doctors, nurses and other clinicians have to take responsibility and learn to act in concert rather than as individuals. As an important first step, we need to find a way to measure continuity so that we can tell if interventions make it better, or worse.

Unfortunately, complexity is making the healthcare experience for many patients seem more and more like a disorganized cacophony, out of synch and jarring, no matter how well each note is played. Continuity and coordination are needed to bring coherence and harmony and they won't come easily.