The Value of Collaboration in a Small Practice

Pediatric rheumatology not only requires close attention to detail when it comes to direct patient care but also effective collaboration with a variety of other sub-specialists.

We commonly consult specialists in nephrology, gastrointestinal disease, ophthalmology, dermatology, immunology, infectious disease, ear, nose, and throat, and hematology/oncology, just to name a few. The diagnosis of some of our more complicated patients requires a couplet or sometimes even a triad of sub-specialists. Collaboration isn’t always easy, and building a trusted relationship takes time and patience, but cementing professional coalitions is often in our patients’ best interests.

Of course, not all academic practices are created equal. In Michigan, we have three pediatric rheumatology practices spread throughout southern Michigan, located in Grand Rapids, Ann Arbor, and Detroit. Our practice in Detroit is on the east side of the state, with just a single rheumatologist. The Ann Arbor center has the most pediatric rheumatologists on its staff, although they perform a considerable amount of research in addition to clinical care. The Grand Rapids center has multiple pediatric rheumatologists on its staff as well and also performs research in addition to its patient care.

In our small academic practice, we have our one pediatric rheumatologist, one nurse practitioner (that’s me), one registered nurse (RN), and two administrative staff that we share with other specialty departments. Each week, we have 22 slots in our schedule for new patients and 51 slots for follow-up appointments. We also dedicate 1.5 days per week to make phone calls, deal with insurance appeals, complete patient charts, and handle other administrative duties that come up. As with many of you reading this, we are thoroughly immersed in patient care every minute of the working day.

With such a small team and a busy schedule, effective communication and collaboration are vital to maximizing our time and best serving our patients. We are fortunate within our electronic medical record (EMR) that we can send and receive messages from other sub-specialists involved in a patient’s care. This method is far more convenient than email. Prior to the recent coordination within our EMR, we would often have to check with individual providers to see which email address they preferred (work or home) or if they relied more on another form of communication (believe it or not, there are still some physicians who don’t use email at all). It was also next to impossible to follow an email chain that included multiple providers. All of these problems led to fragmented, suboptimal care.

The transition to messaging within the EMR allows our team to have group communications that may be saved within the patient chart. We can read the most recent sub-specialist updates and easily toggle back and forth between information related to lab results, medication changes, or other information without going from screen to screen.

That isn’t to say that this transition has been entirely seamless. It’s important to remain respectful of the time and demands of other providers, and some of us had difficulty putting boundaries on the sheer number of messages we could send or reply to. Our RN has learned to be ready on non-clinic days or days when the clinic is slower to triage items that need attention from our provider team. These may involve documents that need a formal signature, new records that require review, medication refill requests, insurance denials, and other materials. The RN also serves as a crucial link between each member of our team, making sure the sickest patients and the most difficult families get the attention they need. She also stays on top of new testing codes or other items that insurance companies need for prior authorizations. It’s often a thankless job, but I know that I could not see and manage as many kids as I do without such an organized, top-notch RN.

While we have learned to utilize the messaging functions within our EMR successfully, our sub-specialty teams have recognized that we still need periodic face-to-face time with each other to discuss our most challenging patients. These face-to-face meetings, albeit infrequent, serve as a good opportunity to build social bridges as well, ensuring that there is a “face” behind the EMR messages.

Within our small department, our rheumatologist and I are in clinic together daily, so we’ll often take advantage of brief openings when a patient is running late or there are unexpected lulls in the schedule to discuss our current cases. As I’ve become more experienced in pediatric rheumatology, I find fewer cases where I need our rheumatologist’s guidance, so our discussions have morphed into a give-and-take regarding our most fragile patients or the current hospital inpatients who will soon become new patients in our clinic.

The improvements that have been made in communication within our hospital over the last few years are significant, but we are still working on improving relationships with those sub-specialists who work outside of our hospital and are involved in the care of our pediatric rheumatology patients.

We work, for example, with external ophthalmologists, dermatologists, and hematologists quite regularly on the co-management of patients. Opening a dialogue with these providers has taken time, patience, and persistence, but I find that once I do manage to speak directly with other sub-specialists, they are so happy that we have reached out to them to coordinate care that the conversation often ends with the exchange of cell phone numbers and the gracious, “Call me or text anytime.”

I’ve also found that once parents know I’ve spoken directly with a collaborating sub-specialist—particularly when they are from outside our hospital—they seem less stressed and tend to be more agreeable with suggested changes in a treatment plan. In the past, I noted parents would often be a little on edge worrying about what their other sub-specialists would think of our suggestions. I don’t see the struggle of them feeling like they are stuck in the middle any more.

Of course, the circle of communication could not be complete if I didn’t talk about parents. Parents are empowered these days through remote access to our EMR, which allows them to view test results, read clinic notes, and send emails directly to their providers. It’s true that I’ve had to spend more time than I might like explaining to the concerned parent that a lab value just barely outside of the normal range is not at all worrisome, reassuring them that nothing bad is going to happen. However, I’ll almost always add, “I’m happy to re-check (the value) next week if it means you will be able to sleep at night.”

Advances in telecommunication and EMR systems are allowing providers to collaborate and communicate better than ever, while at the same time allowing more parents to sleep better at night knowing their children are in good hands. It’s a win-win-win situation all around.

Cathy Patty-Resk, MSN, RN, CPNP-PC is a certified pediatric nurse practitioner in the Division of Rheumatology at Children’s Hospital of Michigan in Detroit, MI, where she provides medical services to inpatient and outpatient pediatric rheumatology patients.