Continuity of care: some experiences and thoughts.

To have continuity, health care must be provided in a manner that includes constant awareness of the patient's past medical history, signs, symptoms, findings, treatments, and responses to treatments, all the while with interrelationships being seen when they exist. One can also make an argument for including being attuned to the patient's feelings about the care provided, because a patient's cooperation is needed to achieve maximum continuity.

It may help to think of continuity of care as being supported by a tripod. Its legs being the patient, the practitioner, and the medical record. Unless each leg supports it, continuity will fall. The two legs that physician executives have direct control over are practitioners and the medical record. The patient can be influenced, but not controlled. Medical professionals have a responsibility to exert that influence through education and how they deal with patients.

The Patient

The patient who seeks medical care from a single source and who keeps that source informed of medical problems and other facts significant to his or her health is clearly the ideal patient for maximum continuity. The patient who self-refers without informing his or her personal physician undermines continuity of care. The same holds for the patient who, rather than bothering his or her physician, goes directly to an emergency department for care. The patient who sequentially uses multiple emergency departments is probably the clearest example of undermining continuity.

Patients who change doctors frequently can also undermine continuity. If the new physician does his or her part, continuity can be maintained, albeit with more work than for an established, long-time patient. Other examples of patient behavior that diminish continuity include repeatedly missing appointments or taking a relative's or friend's medication without checking with his or her physician.

The medical role consists of educating the patient regarding the need for and benefits of continuity and designing care-giving systems to be user-friendly for the patient.

The Practitioner

The term "practitioner" is used here instead of "physician" because of the presence of nonphysician practitioners, who are more commonly found in large, organized group settings rather than in solo physician practices. A large staff- or group-model HMO is an example of the latter type of provider organization. Physicians, however, are the practitioners with the responsibility for ensuring continuity. Is there a difference in the support of continuity between the physician in solo practice and the physician in a large group? There does not have to be.

Although the solo practitioner who sees the patient consistently for all care needed is probably in the best situation to provide continuity, too often it is not achieved. There is continuity in the very limited sense that the patient is always seen by the same physician, but that alone does not guarantee continuity of care. In large groups, while it may be ideal to have one physician, a personal physician, responsible for a patient's care, continuity can be preserved if any practitioner seeing the patient has the patient's significant medical information and also is aware of his or her responsibility and role in maintaining continuity.

My first humbling experience about my role in continuity occurred in the first few years of private pediatric practice. One busy day, a mother brought in her child with an earache, a child who had been my patient for about two years. The diagnosis was acute suppurative otitis media. I knew this child had experienced a number of them. I started paging back through the record to determine how many and their frequency. To save time, I stopped and asked the mother how many the child had in the past year. Her response is still very clear to me. She looked directly into my eyes and politely said, "Doctor, that is what I am paying you my good money to know." She was correct.

That was the stimulus for me to redesign my records. From then on, I had all the significant information on a patient on the first page of the medical record - diagnoses, problems, hospitalizations, surgery, long-term medications, and immunizations. Continuity was significantly improved by my taking this step.

My recent years' experiences as medical director in two IPA-model HMOs has shown, through quality management activities and physician office record reviews, that there is too often a lack of true continuity in many solo practices. We found, for example, the following: prescribing long-term corticosteroids in patients with documented histories of peptic ulcer; penicillin given to patients with documented allergic reactions to it; failure to follow up on abnormal Pap smears; failure to follow up on abnormal mammograms; absence of any chart notes or other records of emergency department visits, hospitalizations, and referral consultations; and, too often, failure to provide routine immunizations and other standard preventive care services for both adults and children.

Achieving continuity of care in a large group can be difficult, but not impossible. Ideally, a patient has one physician in that group with the responsibility to manage and coordinate all care received. Short of that, each of the practitioners needs to be aware of his or her responsibility for continuity. Again, my experiences in two staff-model HMOs have revealed problems with continuity.

In the first HMO, upon becoming chairman of a peer review committee (as such were called about 20 years ago), I thought we were too focused on the past few visits and not seeing the whole picture of what was happening to, and for, the patient in our system. To test this, I reviewed about 20 patient records from the first entry to the last. The results were not encouraging, or surprising. After the findings were presented to the medical group, we revised a number of our systems, as well as our approach in peer review. While a number of problems were discovered, two bear repeating.

One was the finding of a woman who had been seen regularly for chronic arthritis for many years. No Pap smear had been done since her starting her care with us. During one visit, she complained of vaginal bleeding, which turned out to be the first symptom of her advanced cervical cancer.

Another patient had an abnormal barium enema while hospitalized but had no follow up for it after discharge. The report had not been filed in the hospital record before his discharge. It had been sent to us, and our records staff filed it in our medical record's section for x-ray reports, but it was not seen by the physician who was following the patient's progress after discharge.

In the second HMO, the practice had developed of making up a medical record for a patient when he or she first came to one of our centers for care. The problem was that there was a separate medical record for the patient at each of the centers where that patient appeared for care. There is no need to provide examples of the kinds of problems that resulted from that practice. Continuity could not exist unless we changed. To correct it, we instituted a system for identifying which of our many medical centers was the home medical center for a patient and had that center be the one containing the patient's complete medical record. We also developed special encounter forms for visits made to any center other than the home center, with a copy going to the patient's complete record at the home medical center.

The Medical Record

Practitioners who believe they can remember the facts about patients, thereby lessening the requirement for accurate, timely, complete medical records are fooling themselves and putting both themselves and patients at risk. Unfortunately, there are still too many who behave this way. Designing and keeping good medical records is both a discipline and an art. It is a challenge to discipline one-self to do so, but it is well worth the effort. Not only can one have easy access to significant information, but well-designed records can also help lower costs. When I revised my medical records to allow ready access to information, there were side benefits that I did not expect. The same number of patients could be seen daily in less time than when I used my original record format. Reminders of what was due next, and when, were built into the records, which resulted in my receptionist being able to tell a mother who called when her child was next due for something without having me look at the chart and tell her. Also, forwarding medical records to another provider was much simpler, took less time, and cost less. For patients without major medical problems, who were in the majority, we no longer sent a copy of the complete medical record. We sent a copy of the first page, which contained the significant medical information; a copy of the last complete examination, which also included results of routine laboratory studies; and a cover letter explaining what was included and inviting the physician to ask for the complete record if he or she wished it. We received no such requests.

Problem-oriented or source-oriented medical records - which are better? I do not think it makes much difference. Having both, I am convinced a source-job as long as significant information has pointers that, reduced to their minimum, include a medication list, problem list, and the key preventive health services list.

In a large group, obviously, on medical record format should be use by all. Determining it can be a major medical management challenge. The format chosen is not the important factor. What is important is that the medical record needs to support continuity by being user-friendly for the practitioners in its data entry, its ease of finding important facts, and its ability to remind practitioners of upcoming patient's needs.

I have observed excellent medical records, ones that support continuity very well, in both solo practitioners' offices and in large groups. Unfortunately, in both settings, I have also seen records that, while containing all the significant medical information, were so poorly organized that it took a long time to find it. Too often, there is not the time to do so, with timely use of key information being lost.

When working with physicians to improve their medical records, I have found a helpful technique. You should select a few charts from their files, find a quiet time, read through each from cover to cover while imagining the records being those of another physician. This exercise can be humbling and serve as a stimulus to improve the way medical records are organized and kept. I have emphasized that, in particular, they review closely the records of patients whom they see regularly for chronic problems. It is not unusual for such patients to fall far behind in preventive care simply because they believe that, because they are seeing doctors regularly, all care needs are met. But the physicians, concentrating on the progress of patients for particular problems, tend to lose sight of the whole picture of care, which results in inadequate routine health services.

If the three legs of continuity appear to be focused on quality of care, they are. Continuity is a critical component of high-quality and cost-effective medical care. What needs to be emphasized is the physician's (both the practitioner's and the medical manager's) responsibility for achieving maximum continuity. One can have all the tools necessary to do a job, but still not get it done unless adequately motivated. Is more motivation needed than our responsibility to provide the best coordinated care that we can in the most efficient way possible? Can care be the best without continuity? We need to remind ourselves of this responsibility and keep it in mind, holding it high above the distractions of the daily busyness of care. The primary goal of our business, and business, ought to be providing the best care possible.

If more motivation is needed, economic considerations can play a role. Many of us have seen instances of undesirable events or outcomes in patient care resulting from prior information not being readily available. They include inappropriate prescribing, preventable hospitalizations, worsening pathology, duplication of testing, loss of a patient's confidence in the physician, etc., all of which can be unnecessary and expensive. The old saw, "An ounce of prevention is worth a pound of cure," comes to mind. Perhaps we could paraphrase it to say: "A dollar's worth of continuity is worth hundreds of dollars of care."

Patient education, too, is necessary. While I have no hard data, I am convinced that most patients really don't need much education. My experience is that by having the medical records I've discussed improves visits and imparts to patients the feeling that their doctors are aware of, and in control of, all their medical problems. They should be. That is what patients are paying for.