American Medicine: Can we Talk?
So we have a construction project ahead of us. American Healthcare is like an old road with two lanes. The asphalt is cracking and there are potholes every few feet. The demand could easily fill an interstate highway, but all we have is a curvy slow road. We need to fix it without making things worse. We can’t wait long for this to be fixed, since people are being inconvenienced, injured, and even killed by the poor quality of road. Plus, we need to fix it while leaving it open for traffic.
So what is the first step to get this construction going? The very foundation of healthcare that is broken at the root is communication. In previous posts I have documented many areas of breakdown in communication:
- Between doctors and patients.
- Between primary care physicians and specialists.
- Between outpatient and hospital physicians.
If I have a heart attack at a local hospital, go home, and then a month later go to a different hospital, there is very little chance that the second hospital will have any information about that hospital stay accept what I can verbally supply them. The patient is expected to be the vehicle for communication between different segments of the medical system. “You saw Dr. X? What did he tell you?” I ask, as I have no consult note in the chart. “You were in the hospital for two weeks? What were you there for? What did they tell you was wrong?” I ask as a patient is sent to me “for follow-up” after a long hospitalization.
The irony of this is that we live in an age of unparalleled communication. Take this blog, for instance. By blogging I am communicating with people all over the world in an instant. I can call a physician in India on Skype, and can do instant messages with a new friend in Houston. I can get my ideas out quickly and efficiently, and it is extremely low cost to me.
Why should an information age such as this continue to produce medical care that relies on incredibly outdated modes of communication? I haven’t sent my parents a letter in the mail for years, yet we e-mail and talk on the phone regularly. I haven’t gotten a newspaper delivered to my house for 4 years, yet I read the news daily on my Google home page. It is absolutely absurd that we still rely on paper to do the bulk of our communication in healthcare.
It is also ironic to me to read rants against EMR on blogs. Clearly blogging is a means of communication that leverages technology in a major way. Can we envision a system that allows communication to occur via e-mail, secure messaging, and electronic interface? If I can have friends around the world who know what I had for dinner tonight (a great chicken casserole, by the way), why can’t I with equal ease communicate instructions to my patients? Or why can’t the hospitalist communicate with me before the patient gets to my office?
Building the proper infrastructure so this communication can easily happen is the key. If blogging weren’t so simple to do, only enthusiasts would do it. Yet it has been made simple by Blogger and Wordpress. Plus, there is the backbone of the Internet on which the communication can occur. This type of technology could be applied to healthcare. The National Health Information Network (NHIN) and the Regional Health Information Organizations (RHIOs) are two examples of these attempts.
A communication infrastructure is basic to reform. It is impossible to improve the delivery of care if it cannot be analyzed. It is impossible to analyze care if it is not put in a format that allows analysis. The only way to do this is to somehow financially motivate the widespread adoption of EMR. There is no other way. While this won’t guarantee that change will be positive, good communication is a necessary foundation for any hope for healthcare that will be worth practicing in the years to come.
August 14th, 2007 at 1:12 am
Wouldn’t you get a copy of the discharge summary for you patient who has been hospitalized? Is it too skimpy?
Doesn’t a specialist send a letter back to the PCP after a consult? That’s standard here, plus the ER sends notice to a PCP if one of his/her patients goes there. I know that many patients in the US don’t have PCPs but your patients do.
August 14th, 2007 at 5:26 am
That is not the point. I wrote this from the Eastern US in the evening and you answered from Western Canada within hours. If communication can happen that well electronically, then why should we rely on a discharge summary to be mailed or even faxed to my office? Why not have a system that ties physician offices to hospitals, etc. so that we automatically know that the patient was in the hospital. Banks don’t rely on one bank remembering to send a letter that there was a withdrawal. Why should there be that reliance in healthcare?
August 14th, 2007 at 5:40 am
I agree with your premise, but would like to point out that you have one thing about it backwards.
Before I, for one, would be willing to invest in an EMR that infrastructure you’re talking about needs to be in place. Back when I could only talk to others in my university system on my old “intranet”, it wasn’t worth it to get a computer at home because the infrastructure to interact with western Canada wasn’t there. What if they had adopted a system incompatible with mine? Until it’s clear there will be interoperability, the investment is an untenable risk.
It’s like saying “Everyone should buy a cell phone, and then we’ll go set up the tower network so you can talk to everyone with different makes and models of phone.” No way. That’s why so many docs are resistant to adopting EMRs before there’s an overall system. We ain’t dumb.
Sure, many folks (like you) have EMRs and like them. But even you appear to be admitting that it’s only a nice toy for your in-office use. Until it can talk to the hospital and specialists and pharmacies as easily as we can blog, the rest of us aren’t willing to take the risk that the EMR we choose isn’t going to work with whatever communication infrastructure emerges.
August 14th, 2007 at 7:20 am
Another issue is who can contribute to whose EMR. There are privacy issue here in the US. Recall the HIPAA laws? So do you want me to make notes in your records if I see your patient here while she’s on vacation? Do I want you to have access to mine? Or do I simply forward you a copy?
Or do we rely on the patient to update their own, as at iHealth (http://www.ihealthrecord.org/). Then that patient could give us permission to access their record from an ER or our office.
I agree with #1Dinosaur, I don’t want to invest in a system (the old VCR-Beta thing) that won’t work with the hospitals, physicians, patients.
August 14th, 2007 at 7:22 am
I think both things are true. Take the PC and the Internet, for instance. The PC was adopted prior to the Internet - there had to be enough market penetration for the Internet to make any sense. Yet it was the Internet that made the PC ubiquitous. They both had to develop.
My main point, Dino, is that medical societies and physicians as a whole should be pushing hard to get this infrastructure set up, rather than have it be something that is waited for passively. We have a huge stake in this thing working well- both for patient care and (as I will discuss in future posts) the movement of the information “ownership” away from the insurance companies and back to physicians and patients. You may not feel that EMR is mature enough to adopt yet, but you do agree that if done well it can help a lot.
August 14th, 2007 at 8:09 am
Yes, Rob, I agree that if done well EMRs could help a lot.
August 14th, 2007 at 9:33 am
I for one, do not think that armadillos can be housebroken. But if they could, who would want one? If you frightened it, it would jump in the air, knocking off dishes. And it would always be digging holes in the floor.
I understand the desire for better information/communication. But as Illich was fond of saying, too much information is not helpful. (Actually, I just made that up. But his point about the increase in technology is still helpful. The increase in telecommunications actually leads to less real communication.)
Perhaps the real communication still needs to be with the patient himself. I submit that you learn far more from simply seeing and hearing the patient ramble than from the record, no matter how detailed. Even House seems to be learning that.
August 14th, 2007 at 10:10 am
Regarding Armadillos, I just put that up there. I have no proof. I am skeptical as well.
The point of the previous posts and this one is that the patient receives care in many places and none of them are communicating. Physicians don’t even communicate with themselves, often not having dictations back when the patient returns. The number of guidelines and insurance requirements on the physicians are incredibly difficult to manage. That is the ENTIRE REASON for IT. It manages the “too much information” much better than humans do.
I actually do communicate well with my patients, but would rather not have to say “so, have you had any surgery lately?” or “Have you been hospitalized recently? Tell me what happened.” That is bad care. I should be hearing from other physicians. IT allows that communication to happen without the need for as much disruption. There are many examples of this fact in my own practice.
So, Robert, I basically disagree with you. The patient may be able to tell you about their present problems, but even Dr. House looks at the study results and does not say to the patient “what did your x-ray show?”
August 14th, 2007 at 10:28 am
Rob,
I’m sorry, but I disagree with you. Why is it “bad care” to ask a patient if he/she had any surgery in the past year or any changes in their health? I find that it helps my return patients (recall I’m a plastic surgeon and am not suppose to “know” all that has happened to them) and I catch up. It’s like “having coffee” with an old friend. And if I knew everything about their lives would that not be too “Big Brotherish”?
I do agree that it would be nice to get the pathology reports, x-ray reports, etc back in a much more timely fashion. But many of my cosmetic patients would not like for you to know they had Botox or a chemical peel. I do insist that they tell you they had breast implants done.
August 14th, 2007 at 10:33 am
It is fine to ask them. But I just had a patient come in today who was having terrible symptoms and they said that they “had that surgery” and had no idea what it was. She had gotten a Nissen and was now having severe Dysphagia. I had to deduce from my previous notes that she probably had too tight of a wrap with her Nissen because there was absolutely no consult note from the Surgeon (3 weeks out), no surgical note, No hospital stay information. That is dangerous to patients and a total waste of my time.
These patients assume we communicate. I would say that at least 50% of the time, the information is not getting to me. For hospitalists it is even worse.
August 14th, 2007 at 11:08 am
So sorry for you both. So let me play Devil’s Advocate. Did you refer the patient to the surgeon? And if not,did the patient let the surgeon know that you are her primary care physician? And when the patient entered the hospital did they (the hospital) ask who her primary care doctor was or just who her surgeon was (as that admission was for surgery)? What links would be in place (if the EMR did exist) to link this patient back to you and not to another doctor?
August 14th, 2007 at 11:09 am
IT only deals with more information better if it is programmed better, that is, if there is a recognition of what is important. I again submit that neither the programmer or the bureaucrat or the businessman can know that. So perhaps sensitive doctors can advise the process? Even then, who decides what is important? I submit that much of what we do is either not important, or problems we have caused (e.g. your Nissen problem).
August 14th, 2007 at 11:33 am
The patient was referred by our office (that is the only way I knew who she saw), so the office knew who her PCP was. They generally tell the surgeon and also tell the hospital, but for some reason the hospital either does not get them to us, or they are greatly delayed. I cannot tell you how many times a patient has said: “I told them to send you the consult. Did you get it?” and there is none there. Why should the patient be the one responsible to make sure their doctors or the doctor and hospital are communicating.
The ideal solution with IT would be that my referral would be electronic and the consult note would automatically be forwarded to me. I should be registered at the hospital as the PCP, so I should get copies of all of this. Yet again, the intake process is too human-dependent, and the registration person does not always put the right PCP (there is a guy with a similar name to mine who gets a high % of my notes). The less you depend on humans in this case, the less possibility of error. Banks have no problem with this. Why should hospitals?
Regarding Robert’s statement: I will get an equal amount of information either way. Using IT I can organize it well and spend less time searching. If I have a paper chart, I will just have staff sticking the paper into the chart and it is far more likely to be put in the wrong place and/or ignored. The best strategy for error reduction is not trying harder, it is the implementation of a system. Humans are prone to impulse and error and so bad at implementing systems. My EMR will never put a sodium value in the calcium column. Having IT does not increase the information, it just makes it easier to get at what you need. It is far harder to lose stuff when you have an EMR than when you have a paper chart. The Achilles heel to this is not the computer, it is the humans interacting with them (PICNIC = Problem In Chair Not In Computer).
August 14th, 2007 at 11:52 am
Then Rob, maybe we should follow the bank example. In which case, I have a PIN number for my account. Since it is my account, I have to be at least initially (and if I want changes made) responsible for my preferences–PCP, insurance coverage, hospital, relatives to be notified, etc. We could issue a card (similar to my ATM card) that had information about my insurance, doctor, etc. All the providers have to be able to “read” this (some kind of ATM machine). The person at the hospital could then “swipe” it and verify (by drivers license?)that I am who the card says I am (as there is a growing number of insurance fraud case where Ms Jones had a knee surgery but didn’t know she had). This would notify the “system” of the key people to be notified (insurance carry, PCP, etc). But I don’t see how we are going to get around the fact that the patient will have to be involved. If they change insurance or decide to change doctors or move to a new community, they have to “notify” the system of these changes.
I do agree with you that often it is the PICNIC. But even banks are perfect, that’s why they tell you to check your statement at the end of each month.
August 14th, 2007 at 11:53 am
banks are NOT perfect
August 14th, 2007 at 12:03 pm
I agree. What is the first step in the process of accomplishing what you suggest? A computerized system. Of course you want humans to oversee and look for errors. Yet for people to say “human error has got to stop” (ie. they need to send me the dang reports), don’t suggest how to get rid of human error. The best solution? Have an algorithm-driven system that automates as many steps as is reasonable. ATM’s and PIN wouldn’t have happened if banks didn’t first computerize.
August 14th, 2007 at 8:14 pm
In 10-20 years from now we will have a secure health information platform with seamless interoperability between PHRs, EMRs, health plans, labs, radiologic data, physicians and patients. We are on the threshold of taking the first steps towards that goal (a common health dashboard for America). Companies like Revolution Health are pioneers in this field - and are working around the clock to make this dream a reality. It’s not easy, but it will be done. So stay tuned.
August 14th, 2007 at 9:26 pm
And few will be better off. What do you make of the Archives of IM, July 9 study EMR quality measures?
August 15th, 2007 at 5:17 am
Read my post on July 20. The point of this post was not that EMR is wonderful, it is that a system involving an infrastructure of electronic communication would be far more efficient and good for patients than the system we have now. It would set the stage for future reform as well. I think Dino had it right - the efficiencies of EMR are not generally realized because the market is immature. Anyone who does medicine can see that the system is inefficient and can benefit greatly from automation.
August 15th, 2007 at 9:24 pm
Think it’s frustrating for the docs? Try being a patient.
Last summer I was bitten on my hand by me cat (not my armadillo). The next day I went to see my primary because my hand looked like a cantaloupe. He sent me off to a hand surgeon, who admitted me for IV antibiotics. A few days later, after plenty of IV antibiotics and an incision and drainage procedure, I got very bored and wanted to go home. I had to negotiate and transmit information between the hand surgeon, the infectious disease guy and the hospitalist. Turns out, I had been admitted to the hospitalist’s service, so only he could discharge me. He wanted to know if it was okay with the hand surgeon, who wanted to know if it was okay with the infectious disease guy. None of them seemed to be able to talk to each other (even though they appeared to have cell phones and there appeared to be plenty of land lines in the hospital.) Finally, I told the hand surgeon that it was the infectious disease guy’s opinion that I could go home on oral antibiotics I wasn’t lying!), and once the hand surgeon said he could go along with that, I had to tell the hospitalist, who finally sprung me. I thought it was odd that my primary didn’t stop by and see me or have his office call me when I was in the hospital, and I found out later that the hand surgeon never told him that I had been admitted. My primary said if that ever happened again, I should just call his office and let him know. Now apart from my hand being the size of a cantaloupe, I was really in pretty good shape throughout this episode, but I can see how someone who wasn’t all there because of illness, or who wasn’t able to understand what was going on for other reasons, could really get lost in the shuffle. I wonder if EMR that any one of the parties involved could access from any location would have helped fix these communication issues (though an old-fashioned phone call would probably have wsorked just as well).
August 16th, 2007 at 7:37 am
Marian:
This is a perfect example. Yes, a phone call could have helped, but then you have to trust humans doing what goes against their own best interest (it just takes time out of the specialists’ schedules for which they are not reimbursed). Just make it so that the PCP is automatically notified. EMR is part of the solution, but actually not the point of what I am saying. I just think we need to set a communication infrastructure that would actually make these kinds of mix-ups history.
August 16th, 2007 at 10:45 am
“Heat? What’s That? I live in Canada.”
Ummm… hate to burst your bubble, but it frequently gets to be 30-35 degrees Celcius here during the day (86-95 degrees Fahrenheit), and then there is humidity on top of that. Just so ya know…
August 16th, 2007 at 11:48 am
I know that. I grew up in upstate NY, so I know it can get hot up there. It is just not quite what we get here in the Deep South
August 21st, 2007 at 8:23 am
[…] It reminded me of a recent post by Dr. Rob on communication in American healthcare. […]
August 21st, 2007 at 8:24 am
[…] It reminded me of a recent post by Dr. Rob on communication in American healthcare. […]
August 26th, 2007 at 5:48 pm
[…] Death by polypharmacy » Kevin M.D.Kevin commented this week that: … the average Medicare patient sees 3 specialists or more - each prescribing their own set of medications, often without regard to what the patient is already taking. It reminded me of a recent post by Dr. Rob on communication in American healthcare. […]
September 1st, 2007 at 2:50 pm
I’m all too familiar with having to be the messenger between all my doctors.
“Oh yeah, what did Dr. G tell you?
“um, he said he’d talk to you, he didn’t talk to you yet?
“Nope, why don’t you follow up with Dr. G, I’ll talk to him.”
(two weeks later)
“When do you see Dr. S next?
(oh no…)
“um, didn’t he speak with you?
“No, I’ll talk to him, call him to follow up in a week.”
I might be mixing up the order of above events, no matter. I spent a year trying to get an answer and ended up no where.
Still contemplating filing a complaint, but that’d require me revisiting all the events which was stressful, anger-provoking and just generally not good for my emotional state.