Sunday, April 23, 2017

This Is A Really Sad Example Of A Failure Of Knowledge On How The Health System Works And Can Work.

A young doctor saying they are an intern posted this last week.

Why are we communicating so badly?

Authored by James Dando
I AM too young to be familiar with fax machines. My parents had one, and I can vaguely remember them making fun of my grandfather’s skepticism of this “new” technology. I didn’t have to use one. That was until I started working in a hospital.
Now I use a fax machine almost daily, as well as other arcane technologies, such as the pager that has to be carried around at all times.
These rather quaint examples make for fun anecdotes to regale non-medical friends with, but they speak to something more profound: the generally abject quality of the communication tools employed by health care practitioners.
This is especially clear in our handling of medical records. It’s ironic, given that our profession takes so much pride in the ability to tell the story in a succinct and a systematic way, that we are so tolerant of platforms that obscure rather than illuminate the important points in a patient’s history.
Even within a single hospital network, the archive can be dense, chaotic and generally migraine-inducing. It’s not uncommon to find a crucial operation report hidden among a dozen computer-generated data logs or lost at the end of a digital cul-de-sac.
But the real problems start when records are scattered between public and private or across the territorial boundaries of local or state health networks. In this case, chasing the records feels like a fishing expedition, and there are days when the fish just aren’t biting.
Here’s a typical example. A patient who is cognitively-impaired is admitted with a vague history of a previous admission to another hospital following a fall, and it’s thought, reasonably, that retrieving those records may be useful to the current admission.
But on contacting that hospital, which is less than 100 km away, I find that I can’t even be told if those records exist, much less their content. The only way to find out is to start blindly faxing request forms out into the wilderness of medical records. That represents a dismal yield on an investment of considerable amounts of time.
These frequent trips down the rabbit hole in the search for records that may not even exist are really morale depleting. I was prepared by medical school for the stress of dealing with people who are sick. I wasn’t prepared for the task of cold-calling pathology labs around south-western Sydney on the off-chance of turning up an old blood test.
There is a good deal more here:
The way you handle this as an intern is really simple. Just ring the hospital and ask for the medical records department (or the records clerk after hours) and if not helpful – they should be by the way - get them to ring your hospital switchboard and have them page you. This proves to the remote caller who you are. From then they are really obliged to help you with old records for your patient. Same goes for path labs etc. Note of course denying help with a patient who is impaired is deeply unethical anyway. No way, if you are the responsible doctor, can requesting information to assist the patient be a privacy breach or even near it!
Even better is simply to ring the patient’s GP. They are usually more than happy to help and usually the patient or their relative knows who the GP is!!
This all assumes that the patient does not have the relevant details on a sheet of paper (USB stick is a bit optimistic) which should be carried in the wallet of all cognitively impaired patients.
Clearly some 15 years from now, when the myHR is properly populated with information, if ever, then this will be another useful way to go – but of course means you need to be able to establish the patient identity to obtain an IHI and be authorised to access the record. Of course by then most of us might have a digital identity that allows access to local health information held by our GP on line (the UK is moving to this as I type). That would be more reliable than the myHR (which will always be a secondary and often incomplete system).
All in all this article is rather a cry for more responsible information management in the community and care with the travelling patient rather than for a billion dollar + myHR!


Oliver Frank said...

Contacting the patient's usual GP is an excellent suggestion. It would be good if the health system funded GPs for the time that they spend in responding to such requests.

In the UK, hospitals and other parts of the health system don't have to depend on asking the patient or her or his relatives for the name of the usual GP and hoping that the patient or relatives can tel them - they can just look it up. It is time that we had this here.

If nothing else, the MyHealthRecord should have a field specifically for this. The owner of the record could and should nominate their usual GP and general practice, but if they don't do so, this should be automatically populated, based on for which GP's or which general practice's services the person has claimed on Medicare or DVA for the largest number general practice consultations in the past 12 months. If there is a dead heat, the GP or practice most recently visited will be allocated as the patient's usual GP or practice.

Anonymous said...

Thanks for highlighting the inability to have a Patient GP field, rhat explains my puzzlement in why the system default is open to all rather than set to initially only allow the GP, I guess in the belief we are all travelling retiree expected to rock up in emergencies incapacitated, something this simple was over looked.

On the security and privacy front, I believe the government is correct if the read from legislation and documentation, however that does not reflect reality.

Terry Hannan said...

To this I add the following:
1. ALL my patients / carers have a copy of their records -printed or "e".
2. Why? See Larry Weed below who just last week was taking the mickey out of the experts in eHealth ["Medicine In Denial" L.L Weed]
In the latter regard, I remember the day in a medical centre on a ward with a modern information system when they wanted to present a patient to me on rounds.
I said “ Do not present a new patient: tell me who is going home today”.
The nurse volunteered the name of a middle-aged woman who had Lupus for 10 years. I suggested that they give me 15 minutes with the patient and then they could return for discussion.
I asked the patient to tell me all about each of her problems. She knew very little about the medical problems.
“ Do you have a copy of your own medical record?”
“ Are all your medications in your bedside stand, and does the nurse come around at regular intervals to see if you are taking the right ones at the right time?”
“No. The nurse just comes with little paper cups with pills in them, and I swallow whatever is there.”
“ Do you know what a flow sheet is – what parameters we are trying to follow – what end points we are trying to reach?”
At this point I called the staff back together and told them what I had found. Their reactions were:
“ We never give patients their records.”
“ We do not have time to give the medicines that way.”
“ It would not be safe to leave them her with them unattended- she is on many powerful drugs.”
“ The patient is not very well educated and I do not think she could do all the things your questions imply.”
I then said:
“ But you said she is going home this afternoon. She lives alone. At 2 PM you will put her in a wheelchair, give her a paper bag full of drugs, and send her out the door. Are you going home with her?”
“ No. Is her management at home our problem?”
“ You just said she could not handle it – who will do it?”
“ The patient may not seem well educated or very bright to you, but what could be more unintelligent than what we are doing?”
We must think of the whole information system, and not just infinitely elaborate on the parts that interests us or fit into a given specialty. Patients do not specialize, and they or their families are in charge of all the relevant variables 24 hours a day, every day. They must be given the right tools to work with. They are the most neglected source of better quality and savings in the whole health care system. After all:
1. They are highly motivated, and if they are not, nothing works in the long run anyway.
2. They do not charge. They even pay to help.
3. There is one for every member of the population.”