Last week, I received a digital fax of 159 pages from a local hospital. A 159 page PDF. Text not searchable since it’s a PDF of an image.
This is what happens when you are the primary care provider (PCP) — or the geriatrician asked to assist the PCP — and you try to figure out the whole story, in order to understand the medical situation and properly coordinate care.
About these records: they are all related to the patient’s recent hospitalization. The patient’s DPOA requested my help recently, since the patient has been home for a month, is still quite confused and weak, and is having difficulty making the trip to see her usual primary care doctor.
Time required to work my way through them, properly enter information into my EMR, get my own questions about the patient answered, and reach the point at which I could summarize the most relevant parts to another doctor?
Almost two hours.
It’s an instructive example to consider, as we think about how to move towards a system in which medically complex patients can get the right kind of primary care, and follow-up care. Patients like these are the ones who are supposed to benefit from ACOs, and perhaps even Medicare’s new payment of post-hospital care coordination.
So let’s talk about what that care coordination can be like for PCPs, especially post hospitalization.
The patient herself presumably qualifies as a high utilizer, but probably not an exceptional one. She’s elderly, has some chronic problems, was hospitalized for a serious illness, and her hospitalization included about two weeks in the ICU. She was discharged to a rehabilitation facility, she had to go back to the hospital for a week (not clear that her readmission was preventable), she went back to a rehabilitation facility for several weeks, and now she’s been home for a few weeks.
Neither her PCP nor I are affiliated with the hospital in question. This means that we can’t directly access the hospital’s records online. This too, is not an exceptional situation.
The workflow and work of reviewing an extensive hospitalization record
You may be wondering why the heck it took me almost two hours. I’m going to tell you.
Here are the steps I just went through:
- Single 159 page fax arrives digitally in my EMR fax inbox. I was able to open the PDF and view it within the EMR. Practical problems:
- Can’t search the file for specific text, to find answers to my specific questions (such as, did she get a head CT or MRI?).
- Everything mixed together: admission H&Ps, discharge summaries, labs, multiple radiology studies, procedure notes, consent forms. It’s all basically in whatever order the hospital’s medical records staff printed it, and then faxed it. It’s not in an order conducive to my putting the story together in my own head, or in my EMR.
- My EMR offers a text box on the side to summarize key findings within PDFs. Nice when the document holds just one item. Not so useful when the document is a lengthy amalgamation of lots of different items.
- 159 pages need to be sorted, organized, and triaged. Not only do I need to read this information and capture what I need right now, but I need to be able to search through it later on, as additional information queries arise. This means:
- Deleting or setting aside pages that I don’t need now and don’t think I’ll need later (e.g. the umpteen daily chest xrays from the ICU, or the consent forms)
- Finding a way to save the xrays to my xray documents section, the labs to my lab documents sections, etc.
- Adobe used to extract pages and create smaller documents. I ended up breaking the hospital’s fax into 24 documents of use to me, plus one that contained the leftovers (including the umpteen ICU chest xrays). I gave the documents titles that explained what they contained.
- Medical documents reviewed and filed in proper places within EHR. For many, but not all, I used my EMR’s text box to summarize the key points.
- Key information about hospitalization summarized in chart note. By summarizing the main points I’d learned by reviewing the records from this hospitalization, I have something that I can send to other clinicians, or even to the patient’s DPOA.
- I decided to look up a more unusual medical problem. The patient saw several subspecialists while in the hospital. After reviewing the hospital record, I decided the patient’s current difficulties might mainly be related to one particular specialty problem. I look up the problem on Uptodate.com; after all, this isn’t a condition that I co-manage often, and I need to figure out how this problem might be affecting her overall trajectory and prognosis.
- What about a specialist? Well, I don’t know that her outpatient specialist has reviewed all these records, since she hasn’t seen him since being discharged. (He’s not part of this hospital system either.) Plus, she’s feeling too unwell to leave the house often for follow-up appointments. But I have called him and hope to connect with him soon.
In short, I was hindered by:
- getting the information in a non-searchable format and difficult to reorganize format
- having to identify each item and title it myself
- having to spend time properly placing the information in my own EMR
See why care coordination between PCPs and hospitals is often problematic?
Now, it’s true that I work alone in my micropractice, so some of the work I’ve done could’ve been shared with someone else. But there are downsides to sharing this with a non-physician teammate:
- Teammate has to be able to: accurately evaluate value of each page, title each sub-document properly, and file properly in EHR
- Harder for non-physician to determine whether additional info needed from hospital
- Physician needs to wait for teammate to process hospital records –> delay
- If teammate has incorrectly organized hospital info –> further delay
I have to say that I found dealing with post-hospitalization records a real killer at my last job. We often didn’t have the records at the time of the follow-up visit, and when we did have them, the staff had difficulty sorting through a large set such as this one (as did I, riffling through 50+ pages right before walking in to the room to see the patient). I also had much less time to review records, since the practice involved busy sessions seeing patients with relatively little time for care coordination and deeper thinking about complex medical situations.
Lest you think this took almost 2 hours because the patient is relatively new to me: it’s certainly possible that this added a little time. However, at my last job, we often had new or relatively new patients come in post-hospitalization. These were often people who either had not been getting primary care prior to the hospital, or who had decided they were dissatisfied with their prior provider. So a system meant to support PCPs in providing good post-hospital care should not presume that PCPs always are very familiar with their patients.
Could better technology and upcoming innovations help? I think so, and will share thoughts on this subject in the next post.
Clinicians, any comments or ideas regarding your experience reviewing records after lengthy hospitalizations?
[Note: Many thanks to the patient’s DPOA, who gave me permission to share this example on GeriTech.]
In a nutshell
Reviewing the records from a longer hospitalization, and integrating this information into the longer-term medical plan, can be very labor-intensive and time-consuming. When PCPs and other outpatient clinicians aren’t part of a hospital system, receiving hospital records means getting reams of information by fax. This information is usually not searchable on computer, and requires time to sort, summarize, re-organize, and file into one’s own EMR. For a complex hospitalization, the time required can be considerable.
We need technologies and healthcare systems that support PCPs — and other outpatient physicians — in doing this important work.
