Specialist management and coordination of "out-of-domain care".

BACKGROUND AND OBJECTIVES Fifteen percent of Medicare patients receive care only from specialists. This has led to the supposition that there might be a "hidden system of primary care," where specialists provide comprehensive care to their patients, including care traditionally outside their specialty domain. This study explores the perspectives of specialists at an academic medical center on their decisions to provide "out-of-domain" care and how it is coordinated. METHODS We used grounded theory methodology and a constant comparative process with 13 specialist interviews. RESULTS Patient requests drive the provision of out-of-domain care. Specialist comfort with this care and desire to perform it are involved with their decision to provide out-of-domain care. Coordination of out-of-domain care performed by specialists can be difficult and time consuming but is important and is facilitated by electronic medical records. CONCLUSIONS The results suggest that there is no hidden system of primary care. Coordination among all providers of medical care for a patient is needed to prevent medical errors, especially when specialists provide out-of-domain care.