ARTICLE IN BRIEF
As part of a new cooperative initiative to improve the referral process between primary care providers and neurologists, an AAN work group developed a set of checklists in six different diagnostic areas and templates that provide essential information for optimal communication and care about new patients.
Mark Mintz, MD, a neurologist and chief executive officer of the Center for Neurological and Neurodevelopmental Health in Gibbsboro, NJ, has had plenty of experiences over the years with young patients who came to him with scarce information, having been shuttled from one specialist to another with little oversight or coordination of care.
In some cases, the paucity of information — the lack of a complete medical history and a list of diagnostic tests performed — has led to missed or delayed diagnoses for developmental disorders such as autism that would have benefitted from early intervention.
“We see a lot of individuals who have been on the diagnostic journey starting from their primary care physician and going to an array of specialists,” said Dr. Mintz. “We prefer to do the initial assessment, so that there is no delay in obtaining appropriate diagnostic testing and implementing effective treatments.”
It's why in large part he welcomes a collaborative initiative between the AAN and the American College of Physicians (ACP) to improve and streamline the communication between primary care providers (PCPs) and neurologists. The ACP effort — unveiled this past April as part of its High Value Care Coordination Project — aims to improve the referral process between primary care physicians and other specialists, not just neurologists.
This inefficient hand-off process stemmed largely from the absence of a standardized system to guide referrals. “Even terms like the word ‘consultation’ weren't clearly defined,” she added. It often wasn't obvious what the referring physician expected from the specialist — to simply offer advice, remain involved and assist in managing the patient's condition, perform a procedure, or take over a particular aspect of that individual's care.”
The ACP reached out to different specialty societies, including the AAN, to help develop toolkits that include a checklist of information needed for generic referrals to specialists and another checklist for that practitioner's response to a referral request.
The toolkit also includes model care coordination agreement templates between primary care and specialties, and between primary care and hospitalist practices, and an outline of recommendations to physicians and other health care professionals on preparing an individual for a referral in a patient-centered manner.
AAN WORK GROUP
“We really appreciate the fact that the ACP included us in these discussions,” said former AAN President Bruce Sigsbee, MD, FAAN, who served as the liaison to the ACP for this project.
Debuting at a time when increasing numbers of newly insured patients receive referrals through the health exchanges, these measures also guide practitioners in coordinating care within the patient-centered medical home model for complex disorders requiring specialty or subspecialty expertise.
Dr. Sigsbee led a three-person work group tasked with developing templates for the neurological conditions most commonly referred by primary care physicians. These included altered mental state, cognitive or memory difficulties; headaches; numbness, weakness or gait instability; spells (transient episodes of altered consciousness); and transient focal neurologic deficit. The documents described the core information that should be transmitted to the consulting physician.
The AAN Sections provided input on the conditions, templates were revised, and approved by the AAN Practice Committee and finally by the Board of Directors.
“This work group arose because there was a strong sense that in many instances the referral process was broken,” said Dr. Sigsbee, a neurologist at Pen Bay Physicians & Associates in Rockport, ME. “This issue was raised really by primary care physicians, who are typically the referring physicians, even though other physicians can refer as well. But as the process went on and the specialists were part of this discussion, the sense that it was severely broken really came from both sides. It just wasn't working very well, and certainly not to the patient's benefit.”
Consulting neurologists were not receiving key clinical information about the screenings already performed, the patient's complaints, and the reason for the referral, he noted.
“It is not uncommon to see a patient with a one-word diagnosis — for example, weakness — without any other information,” Dr. Sigsbee said, while adding that the medical history, diagnostic tests and other illnesses tend to be missing. “Often, the patient is unaware of the reason for the referral. When asked why they are there, the answer is, ‘I don't know.’ ”
By the same token, referring physicians may feel that they receive little to no communication back from specialists about a patient's status. Dr. Sigsbee experienced this with tertiary referrals, and without a letter from the consulting physician, he was unaware of test results to discuss with an inquiring patient.
Carol Greenlee, MD, an endocrinologist in Grand Junction, CO, who chaired the project for the ACP, said this type of scenario occurs too frequently. Even when the consulting physician receives the patient's records for the referral, they may not be relevant to the office visit. For instance, the records could pertain to the patient's most recent primary care appointment to treat a cold, not the necessary notes about neurological symptoms.
This inefficient hand-off process stemmed largely from the absence of a standardized system to guide referrals. “Even terms like the word ‘consultation’ weren't clearly defined,” she added. It often wasn't obvious what the referring physician expected from the specialist — to simply offer advice, remain involved and assist in managing the patient's condition, perform a procedure, or take over a particular aspect of that individual's care.
WHAT'S IN THE TEMPLATES?
The templates delineate information that should be transmitted ahead of the initial referral visit, while requiring the consulting physician to respond with recommendations and conclusions. They also differentiate between types of consults, ranging from an e-consult to a question via e-mail, and extending to the consulting neurologist's assumption of primary responsibility for a patient with a chronic condition such as multiple sclerosis or epilepsy.
“Some patients are not good historians and have little knowledge of their medical conditions or even the reason for the referral. Some don't even know what a neurologist is,” said Neil A. Busis, MD, FAAN, chief of the division of neurology at University of Pittsburgh Medical Center's Shadyside Hospital and a member of AAN's Board of Directors.
“The referral diagnosis might not be accurate, and we could go down the wrong path during the encounter,” he said. “To prevent such detours, the templates provided by the AAN guide the referring physician to provide more relevant information to the neurologist, so the consult can be more efficient and accurate.”
As health care moves from fee-for-service to value-based medicine, sharing an agenda with internists — who, like neurologists, primarily conduct evaluation and management services rather than procedures — is a win-win situation for both types of physicians, Dr. Busis said.
“We're now sitting at the table with the ACP on a regular basis. This is a huge milestone,” he added. Unlike many requirements for physicians' notes, which Dr. Busis describes as “much more friendly to auditors and administrators than to doctors,” the new templates are patient-centered and focused on actual care rather than billing and coding.
“In the old days, a referral to a neurologist might be one or a few scribbled words on a prescription pad such as ‘altered mental status or ‘TIA,’ ” he said. “We really didn't know the reason for the referral in any detail.”
Now, for possible “spells,” the new template asks the referring physician to provide a brief summary of the case details pertinent to the referral and history. The physician should indicate if the patient has any of the following: prolonged altered consciousness, abnormal movements with episodes, inability to stand at all due to orthostasis, chest pain or palpitations, or any reported focal signs during the episode. Orthostatic vital signs should be checked if the patient fainted with standing.
For possible “transient focal neurologic deficit,” for example, a new template calls for a brief summary of the case details pertinent to the referral, including vascular risk factors and family history. The physician should specify if the patient has any of the following: atrial fibrillation, cardiovascular or peripheral vascular disease, history of similar events, headache, or incomplete recovery. He or she should measure blood pressure and fasting lipid and glucose levels, and also start an anti-platelet agent unless contraindicated.
“This really is meaningful. What we want are meaningful quality measures,” added Dr. Busis, who created an AAN member video about the specialty care medical home model in which he called medicine a “team sport,” with physicians aligning themselves as “team players” on behalf of patients with chronic conditions.
At McFarland Clinic in Ames, IA, physicians already are using a computerized template known as a referral module. “We don't have as elaborate of a process with our referral module when a primary care physician refers someone,” said Michael Kitchell, MD, a neurologist and board chair of the clinic. “They can simply write the reason for the referral. They might have some other information to put in, but it can be just a phrase.”
Without a common electronic health record for physicians to peruse, a template may help address some of the gaps about the patient's medical history, he said.
The six diagnostic categories are helpful to facilitate the flow of better information,” Dr. Kitchell said. “It helps the neurologist get a little more clued in as to what the primary care physician is looking for.”
The AAN work group advising ACP, under Dr. Sigsbee's oversight, not only set standards for communication back to the referring physician, but also offered guidance for patient education. “
There is no attempt to avoid consults,” Dr. Sigsbee said, while acknowledging the shortage of neurologists. “However, most neurologists have more to do than they can accomplish, and saving a few visits by having necessary information initially permits seeing more new patients.”