Blind Medicine

Me: \”So how are you doing today Mr. Johnson?\”
Mr. J: \”Didn\’t you hear?  I was in the hospital for two months.\”

Me: (embarrassed, scrolling through the record)  \”No.  Unfortunately I didn\’t get anything at all.  I\’m sorry you were sick.  What happened?\”

Mr. J: \”I had a heart attack and almost died.  I don\’t remember much about the first week or so.  I was in intensive care for over a week and my kidneys stopped working.\”

Me: \”I had been following your kidney function for a while here.  We sent you to the kidney specialist too.  How is your kidney function now?\”

Mr. J: \”I am not sure.  There were so many doctors.  I was wondering if they got the information from what you did here in the office.  The ordered a lot of the same tests you did.  That seemed strange to me.  The kidney doctor you sent me to doesn\’t work at the hospital I went to, so I was seen by another.  You are serious that you never heard anything, aren\’t you?\”

Me:  \”Unfortunately so.  Communication in our system is terrible.  Why were you there for a month?\”

Mr. J\’s Daughter:  \”Daddy won\’t tell you this, but he actually went into alcohol withdrawal.  I know that you and he had discussed going to rehab for this, but nobody asked.  Momma was with him when he was admitted, but she doesn\’t like to talk about his drinking.  He had seizures, and the doctor told me that this almost killed him too.\”

Unfortunately, this kind of thing is quite common in our system.  Nobody communicates, and the lack of communication is getting worse, not better.  Getting information from specialists and from the hospitals is hit or miss – more miss than hit.  They almost never contact me for information about the care I have given prior to the hospitalization.  In short, everyone is operating blindly.

The Cost

This is serious.  It costs an enormous amount of money; but that is not the worst part of it.  It kills.  Patients have died because of this.

Many patients.

The irony of this is that we live in a time where communication is easier than ever before and when information is easily accessed.  Through my blog, Facebook, and Twitter I have made friends, have renewed friendships, and have communicated my thoughts to an enormous number of people.  I use text messages to communcate with my kids, and plan to do video chat with my son when he goes to college in the fall.

But we all still practice blind medicine on our patients.  As PCP I try to gather the information and serve as a central source, but it takes a huge effort – none of which is compensated.  Since I do the majority of their care and know the big picture on my patients better than anyone, it would seem that anyone else taking care of them would contact me to know what\’s going on.  But nobody does, and the financial cost of this fact is enormous.  The cost to the patient can be bigger than that.

Solutions?

So what can be done?  Certainly a situation this dire (and this is dire) needs immediate attention.  If president Obama\’s first priority in healthcare reform is to eliminate waste, this is certainly a good starting point.  But how can an epidemic this wide be fixed?  It can\’t be fixed quickly, but there are things that can be done to at least get healthcare headed to the 20th century (yes, I meant 20th – much of way our system works relies on 19th century technology).

Here are my suggestions:

1.  Go Digital

Some of care is already digital, but much of it is not.  Lab data, some radiology reports, hospital information (history and physicals, consults, and operative notes), and medication history is usually put into digital format.  Much of medicine, however, is not digital.  Few of my colleagues could e-mail me their consult reports and most PCP\’s still use pen and paper as their mode of documentation.  EMR is not just about computerizing each record; it is about digitizing healthcare as a whole.  My consultants could have me securely email them a copy of my office notes if they wanted.  I have offered it, but none have accepted.  I honestly don\’t think they understand what I am offering; plus, they are used to practicing blind medicine and don\’t like change.

The whole push toward e-prescribing is about digitizing something that desperately needs it.  Medication errors are common, with problems of drug interactions, multiple prescribers, and patient confusion being at the center.  With e-prescribing, doctors have access to a centralized list of patients\’ prescribing history, allergies, and the drugs that are covered on their plan.  It\’s a huge step toward modernizing medicine.

Yet doctors resist this change as well, saying \”what\’s in it for me?\” and suspecting that somehow this is a plot for the government to control more of medicine and reduce reimbursement.  Docs are jaded and cynical.  Some of this is because of the ill-treatment received at the hands of the payers and malpractice lawyers, but I think a large part of it is stupid fear of change.  Yes, we are asked to do work so others can save money, but most docs don\’t know enough about e-prescribing to realize the huge potential upside.  My office is witness to the fact that EMR doesn\’t necessarily decrease efficiency or income.  Most docs think losing money is inevitable with EMR.

2.  Allow Access

I really believe that hospitalists and consultants would look at my records if it didn\’t take a lot of time.  If they could log on and be granted access to information as fast as they can check prices on Amazon, it wouldn\’t be a big issue.  The problem is that medical information is different from any other information.  There are huge privacy walls surrounding health information that make access very difficult.

I don\’t limit allowing access to medical professionals; patients should have access to their own information as well.  As it stands now, most people don\’t know what their last cholesterol was or when their next mammogram is due.  But here also, the laws make most physicians gunshy on sharing (that, and the fact that most of them still use paper records).

Everyone is afraid of HIPAA.  Everyone is afraid of sharing information in an unauthorized fashion and so being open to fines or criminal charges.  The upshot of this is that nobody shares because everyone is scared to do so.  The government needs to somehow make the access to information easier.  It shouldn\’t compromize privacy, but that information is of no use if it is inaccessable.  Somehow the laws need to reflect the reality of the situation now, not what things were like in the 70\’s and 80\’s.  I can check my bank balances online, so why can\’t I log on and find my last blood pressure?  The laws as they are stand in the way of this.

3.  Reward Doing Good

Your system is perfectly designed to yield the outcome you are now getting. This is one of my favorite statements, and it applies perfectly to healthcare.  We have bad care because our system is designed to make care bad.  We have poor communication because good communication is punished while poor communication is rewarded.  Here are some ways this is true:

  • Hospitals don\’t have any reason to give ER physicians access to outside labs or radiology results because doing so would mean lests tests ordered and less income for the hospital.  They are not doing this malevolently (OK, maybe a little), but why should they spend time and effort in doing something that will hurt them?  The system actually rewards bad communication.
  • If I send information to specialists, if anything it will reduce the number of tests they can do.  The outcome for the patient is not rewarded, the complexity of the care is.  This means that docs who communicate make less than those who don\’t.  Would you buy a product that would reduce your income?
  • If I call a patient with lab results or send an e-mail, I do so entirely at my own cost.  Yes, it is part of my job (which is why I do it), but for my efforts to do what is right I am rewarded with a lower income.  The harder I work at including my patient in the process, the lower paid I am.  Add to this the fact that many PCP\’s are struggling – seeing their income drop from lower reimbursement while overhead rises with more governement and insurance red-tape.  It\’s not hard to see why many patients are left in the dark.

Somehow we need to figure out a way that rewards good comunication and penalizes bad.  I don\’t know what that would look like, but the guiding principle of reimbursement should be to pay more for higher quality.  At the present time the opposite is true.

Again, the irony of this post is that I am digitally communicating to people all over the world about the sad state of communication in medicine.  I can use this incredible medium to communicate to you, but at the same time I am handcuffed by a system that barely uses any of this technology.  If we want to really reform healthcare and save money doing it, we need to get out of the 19th century.  This won\’t happen until the government, patients, and physicians all see what the real problems are.

Have I communicated my point?

27 thoughts on “Blind Medicine”

  1. External s – hospitals, other docs – would have to trust your records as much as they trust their own. And, if you give non-medical people access, they’re going to need some training to know what to look for.
    A friend said he’d bring in an xray that was recent rather than get a new one, and his doc said nope; insurance wouldn’t cover him looking at it, then; a new one, they would.

    The most often anecdotal reason for docs not going digital, in my experience: “It doesn’t let me practice the way I want to.”

    HIPAA, not HIPPA.

  2. External s – hospitals, other docs – would have to trust your records as much as they trust their own. And, if you give non-medical people access, they’re going to need some training to know what to look for.
    A friend said he’d bring in an xray that was recent rather than get a new one, and his doc said nope; insurance wouldn’t cover him looking at it, then; a new one, they would.

    The most often anecdotal reason for docs not going digital, in my experience: “It doesn’t let me practice the way I want to.”

    HIPAA, not HIPPA.

  3. Bill: I did not go into much detail, but the basic concept is that if someone has good reason and authorization, they should be able to look at information. The access should be controlled and role-dependent.
    Regarding the second, it only is true for radiologists. I am not paid to read an x-ray, period. But if there is a CT scan report from last week and you go to the ER, perhaps they would be able to avoid getting another. If you had a lipid panel at your PCP, maybe your cardiologist would order another. It happens ALL the time.

    Docs don’t want to do EMR because they don’t have reason to want to. If was clearly to their advantage, they would. There are too many horror stories out there and now there is a culture of negativity toward EMR. I am proof that EMR can be much better than paper, as are the 99% of folks who use EMR and were surveyed to see if they’d go back to paper and said “no”.

    I will change HIPPA to HIPAA. I was thinking about the fat animal.

  4. Bill: I did not go into much detail, but the basic concept is that if someone has good reason and authorization, they should be able to look at information. The access should be controlled and role-dependent.
    Regarding the second, it only is true for radiologists. I am not paid to read an x-ray, period. But if there is a CT scan report from last week and you go to the ER, perhaps they would be able to avoid getting another. If you had a lipid panel at your PCP, maybe your cardiologist would order another. It happens ALL the time.

    Docs don’t want to do EMR because they don’t have reason to want to. If was clearly to their advantage, they would. There are too many horror stories out there and now there is a culture of negativity toward EMR. I am proof that EMR can be much better than paper, as are the 99% of folks who use EMR and were surveyed to see if they’d go back to paper and said “no”.

    I will change HIPPA to HIPAA. I was thinking about the fat animal.

  5. sigh. I will look forward to the one who can solve this problem. Maybe i’ll even promise my firstborn (who is 31 yrs. old).

  6. sigh. I will look forward to the one who can solve this problem. Maybe i’ll even promise my firstborn (who is 31 yrs. old).

  7. Ref (2), I’m not familiar with your HIPAA. Is it similar in intent to our Data Protection Act, which basically requires that “personal data” (which medical records most assuredly are) must be acquired and processed fairly and lawfully, be accurate, and may only be disclosed outside your organisation to the subject and to registered legal entities (this can be done at a business level, so rather than naming all the individual persons with access to the data, you just need to have the Llamatown Medical Practice register that the Alpaca County General Hospital is a data correspondent and vice versa)?

  8. Ref (2), I’m not familiar with your HIPAA. Is it similar in intent to our Data Protection Act, which basically requires that “personal data” (which medical records most assuredly are) must be acquired and processed fairly and lawfully, be accurate, and may only be disclosed outside your organisation to the subject and to registered legal entities (this can be done at a business level, so rather than naming all the individual persons with access to the data, you just need to have the Llamatown Medical Practice register that the Alpaca County General Hospital is a data correspondent and vice versa)?

  9. You sound so much like my own physician. He gets so frustrated with the lack of communication. He wants to know what’s going on with his patients. A patient having to fill him in on what has transpired, is not safe at all.

  10. You sound so much like my own physician. He gets so frustrated with the lack of communication. He wants to know what’s going on with his patients. A patient having to fill him in on what has transpired, is not safe at all.

  11. It is sad, but is the real fact. We, our patients, and the whole health system have the tools, but these are not used, or can´t be used, to keep one stem, one pool, of ordered, fluid, and dynamic information. Wouldn´t it be nice to access under authorization to anyone´s web collaborative electronic medical history, something like a twitter-health-network? Best regards and thank you very much! Yours, Tortadeaceite.

  12. It is sad, but is the real fact. We, our patients, and the whole health system have the tools, but these are not used, or can´t be used, to keep one stem, one pool, of ordered, fluid, and dynamic information. Wouldn´t it be nice to access under authorization to anyone´s web collaborative electronic medical history, something like a twitter-health-network? Best regards and thank you very much! Yours, Tortadeaceite.

  13. I totally agree with what you say. Fortunately, I practice surgery in India and my father is the Physician in the family which at least gives me first hand info on the patients he sometimes refers to me or come across me at my hospital.Let’s hope we can come up with something to see this through.

  14. I totally agree with what you say. Fortunately, I practice surgery in India and my father is the Physician in the family which at least gives me first hand info on the patients he sometimes refers to me or come across me at my hospital.Let’s hope we can come up with something to see this through.

  15. About 3 years ago I started seeing a specialist in a large university hospital… after one year I switiched my PCP to that same hospital and saw a few more specialists. The have EMR and I like it but am also confused at the same time. They have many different clinics all over the city, but all are connected to the university hospital, so one would think that their EMR was connected… wrong. (at least I think).
    It seems like some of my doctors are able to get at stuff done by my other doctors but some can’t… it doesn’t make sense! It’s quite frustrating… but the thing that really annoys me is that they make it seem like they are communicating, by asking who my PCP is… if you not going to tell them anything then why do you need to know who they are??

    But I must say I did have 2 specialists who communicated wonderfully!!! When I would come in to see the one I hadn’t seen as often, she would basically tell me everything the other one told her and then ask if that was true… easy for me!!

  16. About 3 years ago I started seeing a specialist in a large university hospital… after one year I switiched my PCP to that same hospital and saw a few more specialists. The have EMR and I like it but am also confused at the same time. They have many different clinics all over the city, but all are connected to the university hospital, so one would think that their EMR was connected… wrong. (at least I think).
    It seems like some of my doctors are able to get at stuff done by my other doctors but some can’t… it doesn’t make sense! It’s quite frustrating… but the thing that really annoys me is that they make it seem like they are communicating, by asking who my PCP is… if you not going to tell them anything then why do you need to know who they are??

    But I must say I did have 2 specialists who communicated wonderfully!!! When I would come in to see the one I hadn’t seen as often, she would basically tell me everything the other one told her and then ask if that was true… easy for me!!

  17. Am I reading this right? The staff in the hospital seem to have access to EMR but the ones in the remote clinics don’t?
    If so, the explanation is obvious; the hospital has a local network, but they don’t have wide area connections to the clinic sites.

  18. Am I reading this right? The staff in the hospital seem to have access to EMR but the ones in the remote clinics don’t?
    If so, the explanation is obvious; the hospital has a local network, but they don’t have wide area connections to the clinic sites.

  19. That’s not what I said. The hospital has the hospital system. We have our system. We are independent of the hospital.

  20. That’s not what I said. The hospital has the hospital system. We have our system. We are independent of the hospital.

  21. I have a solution- get a copy of your own medical records, and keep them. We move a lot, and a lot of physicians have outsourced their medical records so getting copies everytime we needed to verify some shot, illness etc cost a small fortune. Most of the physicians I have dealt with will now provide a one time copy of the medical record/test immediately after service as a courtesy. While I don’t have the actual CT or MRI images, I have those summaries. Also, I have x-rays on disc, kids immunizations. A folder for each person in the house. When we go to a new provider I hand over the folder and let them copy anything they feel is pertinent (which is often nothing). This has been useful, though, because a provider was able to compare x-rays from years ago to current.
    Every time I have taken a kid to the ER I have been given a discharge summary. This makes it in the folder, too. So I have my own documentation of adverse reaction to vaccine, surgery complication. I make sure primary gets a copy at the next visit. It’s not that hard. People need to take some responsibility for their own health, I think.

  22. I have a solution- get a copy of your own medical records, and keep them. We move a lot, and a lot of physicians have outsourced their medical records so getting copies everytime we needed to verify some shot, illness etc cost a small fortune. Most of the physicians I have dealt with will now provide a one time copy of the medical record/test immediately after service as a courtesy. While I don’t have the actual CT or MRI images, I have those summaries. Also, I have x-rays on disc, kids immunizations. A folder for each person in the house. When we go to a new provider I hand over the folder and let them copy anything they feel is pertinent (which is often nothing). This has been useful, though, because a provider was able to compare x-rays from years ago to current.
    Every time I have taken a kid to the ER I have been given a discharge summary. This makes it in the folder, too. So I have my own documentation of adverse reaction to vaccine, surgery complication. I make sure primary gets a copy at the next visit. It’s not that hard. People need to take some responsibility for their own health, I think.

  23. How would you feel if your bank didn’t keep records but expected you to educate them? That’s how stupid our system is.

  24. How would you feel if your bank didn’t keep records but expected you to educate them? That’s how stupid our system is.

  25. I had a situation over that last year that took many more months than it should have to get resolved because the doc just did not listen to me. Every time I went in, an assistant asked me a bunch of closed ended questions and the doctor came in he already had a preconceived idea. One time the assistant literally rolled his eyes at me and told me they were very busy that day with patients with serious issues. That day the doc literally told me his diagnosis as he walked into the room and told me that pain I felt was not where I felt it but somewhere else. Very condesending, and I knew what he was saying was not the issue. Not only did I have many appointments where nothing got done, I made many phone calls as well. There are now two pages of phone message forms in my chart. On these occasions I would talk to an assistant who would interpret the question, ask the NP, and interpret the answer. I said I was very dizzy. Assistant comes back from NP and says the NP wants to know if I feel like the room is spinning around me. No, I feel like the room is still and I am spinning in the room. I feel like I am going to fall out of my chair. Oh, well, the NP said it was only serious if you felt like the room was spinning. Click. She never asked the NP what she thought of my actual description. And this is a medical office that I have felt very confident with for years. After being told there was nothing wrong with me for months, I finally found my way to an ENT. Diagnosis: Meneire’s (feeling like you are spinning is common with this, and looking back, I realize that I have had symptoms, but to a lesser degree, for years) and chronic sinusitis (that pain really was where I said it was). I know the doc is using the assistants because he has limited time with each patient. And with more routine things I’m actually OK with it. But shouldn’t he have seen that for years I came in only once a year and never called, then I’m in there and calling constantly? Shouldn’t that have prompted him to realize that something was up and that he needed to take the time to really listen?

  26. I had a situation over that last year that took many more months than it should have to get resolved because the doc just did not listen to me. Every time I went in, an assistant asked me a bunch of closed ended questions and the doctor came in he already had a preconceived idea. One time the assistant literally rolled his eyes at me and told me they were very busy that day with patients with serious issues. That day the doc literally told me his diagnosis as he walked into the room and told me that pain I felt was not where I felt it but somewhere else. Very condesending, and I knew what he was saying was not the issue. Not only did I have many appointments where nothing got done, I made many phone calls as well. There are now two pages of phone message forms in my chart. On these occasions I would talk to an assistant who would interpret the question, ask the NP, and interpret the answer. I said I was very dizzy. Assistant comes back from NP and says the NP wants to know if I feel like the room is spinning around me. No, I feel like the room is still and I am spinning in the room. I feel like I am going to fall out of my chair. Oh, well, the NP said it was only serious if you felt like the room was spinning. Click. She never asked the NP what she thought of my actual description. And this is a medical office that I have felt very confident with for years. After being told there was nothing wrong with me for months, I finally found my way to an ENT. Diagnosis: Meneire’s (feeling like you are spinning is common with this, and looking back, I realize that I have had symptoms, but to a lesser degree, for years) and chronic sinusitis (that pain really was where I said it was). I know the doc is using the assistants because he has limited time with each patient. And with more routine things I’m actually OK with it. But shouldn’t he have seen that for years I came in only once a year and never called, then I’m in there and calling constantly? Shouldn’t that have prompted him to realize that something was up and that he needed to take the time to really listen?

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