Cardiology in the community: integrating care through professional communication in Singapore

INTRODUCTION

The phone call came in the middle of a busy ward round with Dr Mark Cooper, but he took the call anyway, interrupting our discussion about the patient we had just seen. “David, what can I do for you?”, he said in his usual calm, soothing voice. It was one of the general practitioners in Western Sydney who had just seen Mrs E, a shared patient of theirs; he was concerned that she was doing rather poorly. “How about we do this, David, ask her to increase her frusemide to 80 mg daily, and I will see her on Friday in my clinic?”, Dr Cooper replied after a while. He ended the call, and we resumed rounding without missing a beat. These phone calls peppered our ward rounds with every consultant I worked with at Westmead Hospital Sydney, Australia. It was so routine, yet each call probably averted an emergency department presentation and helped to keep the elderly Mrs E out of the hospital.

It takes an integrated healthcare team to keep Mrs E independent, living at home and being able to get her gardening done as best as she could. A key enabler for this is clear and timely communication between the many healthcare providers a patient may encounter. This is especially important as we move towards shared care of patients with chronic conditions. The aim is to anchor their care in the community as advocated by Healthier SG.[1] Patients expect their healthcare providers to talk to one another and to know what is happening to them, but as healthcare providers, we often fall short of this.

CHAT GROUPS AS VIRTUAL CURBSIDE CONSULTATIONS

Communication between primary care and tertiary care has always faced many challenges, including different locations, separated electronic medical record (EMR) systems, and time constraints during working hours. As a result, the transfer of patient care and information has often been unidirectional [Figure 1]. Typically, the path of least resistance is for primary care doctors to refer patients to specialist clinics or emergency departments. Many of these care transfers may occur with limited communication between the healthcare providers. Yet, it has been shown that interactive communication between primary care doctors and specialists can improve care, such as improved glycaemic control in diabetic patients or depression scores in psychiatric patients.[2] Furthermore, curbside consultations receive high levels of approval amongst clinicians who participate in them and may provide cost-effective solutions to improve the quality of care.[3] In 2022, the National University Heart Centre, Singapore set up mobile phone chat groups with our primary care colleagues in the National University Polyclinics (NUP), followed by our primary care networks [Figure 2]. This was an extension of our chat groups with the doctors and nurses in the nurse-led integrated care clinics at Bukit Batok Polyclinic since 2018. Although asynchronous, these chat groups function like virtual ‘curbside consultations’ and allow for relatively rapid access to expert opinions about electrocardiograms and other clinical management issues. This often avoids unnecessary referrals to our specialist clinics and occasionally leads to expedition of care.

Figure 1.

Chart shows the transfers of patient care and information.

Figure 2.

Example of chat group discussion of patient with Brugada Type 3 electrocardiogram pattern and how to manage such patients.

Importantly, the chat group is a channel for informal education on the management of cardiac conditions, as the advice given can be seen by all the doctors in the chat group. A notable observation we have made in some of these chat groups is that the queries are always pertinent and the same question is never asked twice. Hopefully, this is a sign that we are all learning together. Another important effect of these chat groups is that we build a ‘community of care’ through these networks between specialists and primary care providers, and we now receive direct calls or messages for advice on complicated patients who may need more urgent help.

It was possible to set up such chat groups largely due to our longstanding working relationship and personal friendships with our primary care partners. Finding willing collaborators on both sides was key, and it was important to identify both clinical champions and administrative support for this work. While we did not specify response times for our chat groups due to the informal set up, our experience was that having younger cardiologists helm this is highly beneficial. They tend to be much more comfortable with and responsive to mobile messaging, and most queries are answered within a few minutes to a few hours. As these groups become formalised, we plan to introduce more defined response times.

Further support is also at hand through our virtual care centre (VCC) where primary care doctors can ask for advice over the phone if the matter is more pressing. The phone lines are staffed by care managers who triage the calls to the appropriate specialists. This is especially helpful for patients who have been recently discharged from our hospitals and may be on the verge of an avoidable readmission. For those who are truly unwell, the VCC can arrange for direct admission to a hospital ward or referral to NUHS@HOME, our medical inpatient home care service, avoiding a long sojourn through the emergency departments.

MEDICOLEGAL CHALLENGES

Advice given over the phone or in chat groups is similar to curbside consultations in many ways. These ‘curbsides’ are a cherished tradition of medical practice and are not only a part of clinical care, but an opportunity for medical education. Freely sharing professional opinions in collegial exchanges have, till now in our local context, been governed by good faith, personal integrity and professional courtesy. However, one concern about these informal consultations is the medicolegal implications of advice given in these settings. While it is generally considered safe from liability in the United States if they are truly curbside,[4] this has not been tested in Singapore. Carrying out curbside consultation via digital communication adds another layer of complexity, as there is now a record of the consultation. Virtual consultations that are recorded in a patient’s medical record, such as those done at the VCC, are likely to be considered a formal consultation, and hence carry the same medicolegal weight. However, the nature of informal chat group advice is less clear. Cases are typically discussed with incomplete information, and the specialist is neither afforded the opportunity to look at the patient’s medical record nor able to conduct a physical examination. Does this interaction incur a duty of care for the specialist? It is arguable that not having full access to clinical information protects the specialist from liability and that the primary care doctor bears the duty of care for these consultations. These uncertainties have made some physicians reluctant to share their expertise for fear of being sued. In order for this type of professional communication to be more widely practised, it would be important to clarify the definition of a curbside consultation and the medicolegal liabilities that it entails. We believe it would be preferable for policymakers to resolve this issue, rather than allowing it to be determined through legal suits. The former approach will likely take a shorter time and reach a more balanced solution that will foster more effective interprofessional communication.

ACCOUNTING FOR EXTRA WORKLOAD

A defining feature of curbsides has been that they neither attract a fee nor are recorded as an official workload for salaried staff. For workplaces that use itemised clinical load as part of performance review, physicians who engage in significant amounts of curbside consultations may be disadvantaged by engaging in this unrecorded work. With electronic consultations now increasingly common, it may present an opportunity to explore ways to quantify this work. However, charging fees or counting curbside consultations towards clinical workload may have the unintended consequences of formalising these interactions and perhaps heightening medicolegal jeopardy. A possible way forward would be to recognise physicians’ contributions to this work in other ways, such as with a fixed monthly allowance or time off-in-lieu so that they are rewarded for the extra work.

ENABLERS FOR IMPROVING COMMUNICATION AND SHARED CARE

Currently, most interprofessional communication takes place between healthcare providers within the public health clusters. To allow these avenues of communication to expand beyond the public system to primary care, several enablers need to be in place.

Firstly, only primary care doctors in the polyclinics currently have full access to one of two EMR systems, but soon, all three clusters will be on a unified EMR that gives unprecedented access to patient data across the country. Moreover, private primary care doctors will also receive greater access to these medical records as uptake of the National Electronic Health Record system improves, resulting in far more integration, which will make shared care easier.

Secondly, a secure form of communication is needed, especially if patient identifiers need to be exchanged. The chat groups in operation now run with strict rules, such as excluding patient identifiers in any messages, but when a more detailed review is needed, the specialist will need the patient details to access the patient’s EMR. Hence, a secure messaging platform is required, and there are proposals to make this available to our community doctors.

CONCLUSION

Shared care of patients with timely and effective professional communication improves not only clinical outcomes, but also the satisfaction levels of patients and physicians.[5,6] It can also potentially avoid unnecessary referrals to emergency departments and specialist clinics, helping us stretch our limited healthcare budgets further. This, then, allows us to achieve not just the triple aims of care as proposed by the Institute of Healthcare Improvement,[7] but also the quadruple aim of improving our healthcare providers’ experiences of delivering care.[8]

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.