Around 450 BC, the Greek philosopher Zeno proposed a physics/math problem that stumped natural philosophers for centuries. His proposition was simple: that motion is an illusion because a moving object, in a single instant of time, can be seen as motionless. If a moving object can be considered motionless, even during the briefest moments, how can motion possibly exist? While this notion may seem absurd to us and probably to the rest of the Greek world back in 450 BC, an elegant solution did not arrive until more than a thousand years after Zeno when Sir Isaac Newton and Gottfried Leibniz invented differential and integral calculus.
Unfortunately, we have a similar problem in medicine today, especially within the Acute Care Continuum. For example: how many times do ED docs see a patient with the same complaint in spite of more than five prior ED visits or hospitalizations? And when the patient reappears, is information available so that forward progress can be made with the patient’s chronic problem? With the presence of so many providers across the inpatient care continuum, (ie. ED physicians, PA/NPs, hospitalists, Skilled Nursing Physicians, extensivists and home visit physicians) it’s likely that the information accompanying the patient’s journey has become fractured and “dis-continuous.” In spite of electronic medical records (EMRs), many of these patient “frequent flyers” have medical documentation that lacks a sense of care planning at best or, at worst, seems completely incoherent.
As a result, “medical paralysis” occurs – as a system. We end up obtaining tests such as troponin assays or cardiolyte tests on bedbound patients with end stage dementia, or order screening colonoscopies on those with terminal metastatic cancer. If we had a sense of complete information on these patients, we would be certain not to order such unnecessary tests and procedures. They are ordered nonetheless because we lack prior knowledge of the patient. Unfortunately, the patients fail to improve and they usually cycle through the system again at another hospital. They continue to receive tests and procedures, but remain motionless with respect to their condition – a medical Zeno’s paradox.
The Acute Care Continuum’s strategy of integrating ED and hospitalist workflows represents an important first step towards breaking this motionless cycle. But the greatest portion of the work belongs to the physician Partners who will use this opportunity to create novel ways to pass information and, most importantly, to create a sense of management and planning for patients as they pass through the Acute Care Continuum. Some may view patient transitions within the continuum similar to a “baton handoff” in a relay race. But perhaps a more accurate picture would be a rowboat with many oarsmen (ie. physicians and extenders) who all rotate at the coxswain (steering) position. All healthcare providers impact patient care at all times, and if a physician transitions (or rows) poorly, then performance of the entire crew decreases.
The obvious solution to this issue rests in the way we see information as a medical community. We need a system that keeps information centralized and easily accessible. But it also means retraining physicians to document patient conditions beyond the static “medical history and physical” to a more dynamic approach that focusses upon how the patient is different from baseline at the time of evaluation. And it also means creating tighter relationships among inpatient providers and a team-based approach to healthcare. These, in turn, will discourage waste and redundancy. While payers are retooling reimbursements in order to incentivize this way of thinking, there still is no unified solution. This represents tremendous opportunity for all of us who participate in hospital-based care. Unfortunately, given the United States’ current consumption of healthcare, we have far less time than a thousand years to conceive a solution.