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MISSING PIECES OF THE PUZZLE
Patching Holes Created by Episodic Care

Episodic care describes a pattern of accessing healthcare that is intermittent and fragmented— essentially, lacking in continuity.

Could a mathematician solve a complex equation if critical information were inaccurate or missing? Unquestionably, having the right data is a threshold requirement to achieving the proper result. In medicine, the same is true when a clinician seeks to diagnose and treat the patient who has received only episodic care.

Episodic care describes a pattern of accessing healthcare that is intermittent and fragmented—essentially, lacking in continuity. For any number of reasons, the physician never becomes familiar with the patient’s medical history or the patient’s individual health needs. Episodic care can seriously jeopardize patient welfare and presents a substantial liability risk to the physician. There are different faces to episodic care:

• The patient who sees more than one physician, either within one practice or at different locations. Often, these physicians see the patient without benefit of a complete medical history or access to the patient’s medical record. The physician may assume that someone else is acting as the patient’s primary care physician.
• The patient who presents to the same physician over time for the treatment of a variety of minor problems without ever giving a complete medical history, having a physical exam or following up for preventive health maintenance screenings. The physician detrimentally relies on the patient to follow-up for these additional healthcare needs.

Dr. Reza Danesh, a MPTMember in Long Beach, recalls a “near miss” related to the inherent deficiencies of episodic care when the patient presented to several providers at different locations. “Early in my career I worked as a locum at an urgent care center for a multi-specialty group with multiple office locations. A patient I’d never seen before told me that no one was able to cure him of his sore throat and neck pain. After digging a little, I learned that the patient had been treated with antibiotics for pharyngitis over a 6-7 month period. He had been seen at two different locations by numerous providers. X-ray revealed a 3 cm mass pressing on the trachea and esophagus. That experience taught me that being a good historian is crucial, especially since patients sometimes see multiple providers for a variety of complaints and don’t always know to offer information about their past medical history that might be medically significant.”

Lee Kissel, MD, another MPT-Member in Manhattan Beach, corroborates this view. “My work as an expert witness reinforces the importance of obtaining a thorough patient history. Whenever a patient is unfamiliar to me, I always make time to ask basic questions about medications, family history, prior hospitalizations and other treating physicians. When the patient is due for screenings, I clearly explain the significance of the test and document the discussion as well as the need to follow-up. In our office we attempt to pre-schedule patients for follow-up, knowing full well that their non-compliance can become our liability. Also, in our busy group practice, we have to see each other’s patients. We find that an updated ‘PROBLEMS LIST’ is invaluable for communicating important information amongst providers.”

Closing the Gap
At its core, episodic care is about information deficit. Although there might not be any single method for obtaining the data, the following are a few risk management suggestions for patching the holes created by episodic care:

• OBTAIN and review the patient’s medical records (and document your efforts to obtain them).
• UPDATE health histories frequently. At the orthopedic practice of Dr. Michael Schiffman, a MPT-Member in Los Angeles, medical assistants help patients complete an “Interim Health History” form at the beginning of each visit. The form is brief and asks the following questions:
• Since your last visit, have you…
  • Seen any other M.D.s?
  • Had any diagnostic tests?
  • Started any new treatments?
  • Begun taking any medications? What kind?
• DOCUMENT your reminders to patients of recommended health screenings and explain the purpose of the test in layman’s terms. For example, telling a patient “You’re due for a PSA,” might be lost on the patient, whereas explaining that the test is necessary to determine the presence of prostate cancer underscores its importance.
• PRE-SCHEDULE patients for follow-up appointments before they leave your office and document your attempts to contact them when they are a “no show.”
• ORGANIZE information with tabs or dividers. Preprinted forms are invaluable, especially in group practice where documentation styles are as individualized as signatures. Forms prompt and organize crucial information that might otherwise be buried or marginalized. Use problems lists, medication lists, and recommended health screenings — using these, everyone knows where to look!
• FLAG IT! At another MPT-Member, Dr. Olivia Crookes’ OB-GYN practice in Santa Monica, physicians share patients. They know that when it’s crucial to communicate with each other (e.g., the history of pre-term labor of an expectant mother), they “purple flag” it. A purple post-it note is attached to the most recent page of a progress note bearing the crucial information. Everyone picking up that record sees the item.