In my medical practice, lacking the tools to communicate meaningfully with other providers who are caring for my patients is a daily frustration. This is only magnified when it comes to caring for my most vulnerable patients who have difficulty communicating for themselves, such as those suffering from substance use disorders (SUDs), so I was glad to see this topic addressed by D’Annuno and colleagues in an article published ahead of print this month in Medical Care.
This is how a typical scenario might play out: I see my patient, Sara, in clinic for a rash. I tell her I think it’s a skin infection related to injecting heroin, and as we discuss how and why this happened, she asks about treatment for her addiction. We call around to a few treatment centers and luckily find one with an open spot – we give Sara the address and send her over for an intake. Most of the time, I never hear anything further until my next appointment with her.
This is tremendously frustrating, because often when the patient returns, we find out that there was some kind of barrier preventing her from enrolling in the program – they didn’t take her insurance, for example, or the hours of the program conflicted with her job or childcare. If we had known about these barriers, we could have facilitated a referral to another treatment center. Even in cases where my patient enrolls successfully, sometimes I might get a fax a few months later informing me that the patient completed the program, but more often, I don’t hear anything.
Is there any other industry in the United States where fax remains a prominent communication tool?
My experience is typical, as it turns out. D’Annuno and colleagues set out to examine how many Addiction Treatment (AT) organizations have formal contracts with Patient Centered Medical Homes (PCMHs) and what type of information the two groups exchange, given that performing care coordination is a requirement for PCMH certification. They surveyed a national sample of AT organization administrators (n=695) and found that only about 10% of them had formal contracts with PCMHs in the community, with another 12% planned or in discussion; this translates to 38% of US patients receiving treatment in AT organizations that have a contract with PCMHs. However, only 6.2% of patients in states that have not yet expanded Medicaid were receiving treatment at a provider that contracts with PCMHs, compared to 51% of patients in Medicaid expansion states. D’Annuno et al rightly find this notable, since people newly enrolled in Medicaid often have significant unmet AT needs – this could be evidence that PCMHs in states with the Medicaid expansion are responding to this need by establishing contracts with AT organizations.
Most significantly, only about 30-40% of the existing linkages between PCMHs and AT providers included actual exchange of information about the patient. There is good reason for that – handling confidential patient information requires the utmost caution. In 2014, only 42% of all US providers were sharing data with other providers, and some AT organizations still use paper charts, so direct sharing of patient information may not even be possible in some cases.
Email is a convenient method of communication if HIPAA-compliant encryption features are available, and if it is possible for the primary care team and AT team to establish such communication – but this is very rare because clinicians don’t routinely share email addresses across organizations. Telephone calls often lead to navigating endless phone menus or playing phone tag. Thus, in all of the clinics where I have worked, fax remains the most common method of communication with AT organizations, visiting nurse programs, and community based organizations such as elder services. Is there any other industry in the United States where fax remains a prominent communication tool? (And I am not the first person who has asked this question!)
Communicating with AT organizations and other community partners is an area where primary care must improve dramatically in the coming years. Novel payment models recognize the need to address social determinants of health, and they will require primary care clinics to work closely with community-based groups as partners in improving the health of our patients. In Massachusetts, Medicaid will soon likely shift from a Fee-For-Service (FFS) payment structure to Accountable Care Organizations (ACOs), and some funding will go directly to community-based organizations and long-term services and supports for patients. Exactly how the money will be disbursed is not yet clear – but provider organizations will now have financial stakes in improving our communication and coordination of care with community partners. I hope we can do better than the fax machine.
Audrey Provenzano