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.
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.
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.
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?