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Lack of "Continuity of Care" Can Kill

For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.

Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:

Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.

Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.

So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.

Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.

How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.

There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?

This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.

I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.

What do you think?This post originally appeared on Dr. Val’s blog at

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5 Responses to “Lack of "Continuity of Care" Can Kill”

  1. Dr. Wes says:

    Couldn’t agree more.  Just one problem, though.  Who’ll replace the exodus of primary care doctors and pay for the EMR’s?  While the government might be able to subsidize the EMR’s, it’s funny how the presidential campaign trail consistently fails to mention the dirth of remaining primary care doctors in their ever-expanding hype for correcting the healthcare morass today.  If you ask me, unless our leadership understands this critical element, any other “reform” is doomed to failure.

  2. tstitt says:

    A few years ago my mom fell and broke both wrists. I volunteered to travel from CA to MA to help her and my dad with the first week of recovery. I was thinking “cook, clean, errands and host well-wishers.”  While her outcome and recovery was positive and her care team was quite responsive, nobody had provided my mom or dad with an aftercare/physician responsibilty roadmap that they could follow. Continuity of care is really important. Electronic healthcare standards/records to enable rapid data exchange between different healthcare providers would be a huge help. How about also upgrading discharge instructions from a stack of generic text (or handwriting) on paper and verbal instructions (that none of the family after-care givers heard) to online audio/video media (podcasts?) and graphically compelling print materials?

  3. Anonymous says:

    Touching story, but electronic medical records do not seem to be the answer to the questions it raises. Since the patient never took the meds which the doctors thought she was taking, would the story be any different if the doctors had looked up her prescriptions in an EMR rather than on a list given to them by the son? Probably not–they would have read what drugs Frannie had been prescribed and still seen how much water she was retaining by looking at her ankles. (Did anyone actually ask her whether she took her pills? Did anyone count the pills or ask the son to count them?) Would “frantic” specialists have (or take) the time to read information in electronic form that they don’t have the time to read on paper? I don’t know for sure, but I am probably not the only person who has seen doctors frantically reading my folder as they fly through the door of the examining room and then asking me the same questions the nurse had already asked and recorded. How will electronic medical records systems deal with data errors, which propagate through databases at lightning speed and are almost impossible to fix? The diagnosis of advanced dementia would have been entered into Frannie’s medical record, where it would have become “truth” because many people believe what they see on computer screens more than they believe what’s in front of them.

    EMRs are being presented as The Answer to the problems of our healthcare system, but what made the difference to Frannie is that a physician, who happened to be a family friend, took the time to unravel her problem and changed her treatment. Accuracy of records had very little to do with it.

  4. ValJonesMD says:

    Dear Anonymous,

    Thank you for your
    well reasoned and nicely written response. I agree with you that EMRs
    are not the whole solution, but I do think they’re an important piece
    of the puzzle. If there had been an EMR (and/or a service like All
    Scripts in place where pharmacies track repeat or redundant
    prescriptions) in place, she wouldn’t have wracked up 3 different sets
    of diuretics (no one doctor would have given her 120mg of lasix,
    because even as rushed as they are, that’s just a ridiculous dose).
    When it came time for her son to give her the meds, he wouldn’t have
    had a dangerous triple dose. Also, if the hospital had access to her
    records (where there shouldn’t have been any record of dementia to the
    extent witnessed, and her social history should have documented that she was
    independent with ADLs) they would have been triggered to think twice
    about “end stage dementia”

    However, you’re right that the doctors
    are partly to blame too – because they didn’t do their investigative
    work. No one felt personally responsible for Frannie’s welfare, no one
    was championing her cause and keeping a longitudinal eye on her. That’s
    where the lack of a primary care physician comes in. Frannie should
    have had one primary doctor working with her, admitting her to the
    hospital if needed, and coordinating her care.

    As to your point
    about propagation of errors in EMRs, that is an extremely good point,
    and the most concerning potential danger with them. Nonetheless, I
    wouldn’t throw the baby out with the bathwater there. Creating a
    central database of information can help a lot – but as you say,
    ultimately the best shot that a patient has for good care is a caring,
    conscientious doctor who knows them well. For some patients the best
    they can hope for is a family friend. And that’s really tragic.

  5. C Coleman Brown MD says:

    The EMR is not the only answer, but a significant part of it. For instance, I am about to operate on a patient today and because her old hospital (an Extremely well known Maryland area “Institute”) cannot locate her old operative reports, I am forced to change my surgical plan for her cancer reconstruction. If this information was centralized and accessible by the physicians treating each patient, it would certainly make things better.


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