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    Primary Care and Hospitalists: Improving the Relationship

    In the past 15 years, we"ve seen the growth of a new specialty, hospital medicine, which started at the end of the 1990s.[1] The term "hospitalist" was coined by Dr Robert Wachter for physicians who spent most of their time taking care of patients in the hospital. This specialty came into being because these patients were sicker, required more complex care, and required real-time care with physicians being present. Hospitalists today are the fastest-growing specialty physicians in the United States.

    Over the past 5 or 10 years, we"ve also seen another trend. Academic medical centers, hospitals, and community health systems have been purchasing outpatient practices of ambulatory physicians. Today, about 58% of family medicine physicians and 50% of internal medicine physicians are employed by health systems. We also see this with multispecialty practices, where about 40% of them are associated with health systems and about 20% are associated with single-specialty hospitals. Today, we have a number of our physicians who are employed in both the inpatient and outpatient settings.

    The opportunities to improve care are provided within these centers. Many of these centers have their patients being seen by physicians in both settings, and they utilize a single electronic medical record.

    There are many advantages to having outpatient ambulatory sites and inpatient physicians having patients" care on the same patient portal where the patients also have access to the system. Some of the benefits include that there is a patient history readily available. You actually know who the physicians are the patient has seen from a specialty, and from a primary care perspective, and you have their results. You"re aware of the different community resources that a patient has had. This allows beginning an easy communication between physicians, even if they"ve met only once or twice, allowing for easier diagnosis, easier treatment protocols, and transitions back into the community.

    Because these physicians all work within the same health systems, it"s extremely important that there are great communication modalities set up so that all of the physicians within a health system are hearing the same message. This is done in different ways by different hospitals.

    For many health systems, there"s an onboarding system for physicians where they"re hearing about the evidence-based guidelines that are standardized throughout the entire health system. Many of these are embedded within the electronic medical record. For example, whether you are a physician in the outpatient or inpatient setting, if you"re treating a patient with diabetes, there are flags generated that make you aware of the different metrics, be it foot exams, eye exams, or hemoglobin A1c levels. There"s a record, and there"s actually a prompt.

    The other pieces of information that can be embedded in an electronic medical record shared by all physicians are patient education materials that are, again, prompted to be shared with a patient. These usually are developed to be culturally appropriate and health-literate.

    Electronic medical records form a basis for improving communications between inpatient and outpatient physicians. Putting training into place so that physicians are aware of the tools and how to use them is very important.

    First, having training courses helps. Second, have actual onboarding events where physicians get to meet each other. Even today in our technological world, having a face-to-face meeting allows you to see who you"re referring patients to and allows you to build a relationship with that person. Many health systems, including mine, host these events a couple of times a year, particularly for new physicians so they can meet the physicians who they"re working with, meet the other departments, and begin to feel comfortable making referrals and accessing some of the tools.

    The third very important modality in allowing there to be standardized, evidence-based care focused on outcomes is having the chiefs of divisions and departments emphasize its importance: "This is how we"re all going to work, and I"m available to aid you in making that happen. Here is where the resources are. Here is what"s done in my department to allow that to occur."

    The are multiple benefits for institutions, clinicians, and patients in this type of setting. For patients, their own primary care physician can say to them that they know the physician whom they will be seeing on an inpatient basis. More important, they"ll have access to all of the information that I have in the inpatient setting. They can provide the best care to you, speeding up your treatment, and allowing you to receive care on the outpatient setting that I will be aware of.

    For the clinicians, they will not be repeating tests. They will be providing care based on evidence-based guidelines that are available to them within an electronic medical record. Again, they know what"s occurred before and what the sensitivities may be for the patient or, based on the community resources that have been used before, what the patient has access to.

    The benefits for a health system are improving quality of care. You have evidence-based guidelines that you"ve standardized on an inpatient and outpatient basis. You"re able to look at transitions of care for patients, knowing that they"ll be going back to the physicians whom they were seeing on an outpatient basis. In a value-based environment, you can actually track metrics throughout and share them with the physicians, both inpatient and outpatient, so that you have a quality improvement system where people have access to data.

    Hospitalists are the fastest-growing medical specialty. In the late 1990s, there were about 100. Two years ago, there were about 44,000. They continue to be a growing specialty, with a great deal of interest by young physicians in particular. This has occurred because there is a need and because there"s a lot of great innovation occurring in hospitals. There is also a growth in primary care physicians for some of the same reasons. The partnership between these two will continue for the next number of years. It"s a great opportunity for us to continue to provide patient-centered care.





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