GeriTech

In Search of Technology that Improves Geriatric Care

Resolutions for 2013

A little goal-setting can be a good thing. Here are a few for me this year:

1. Have another clinician write a guest post. As fun as it’s been to monologue away, I’d like to get a few other people’s perspectives on the blog. The goal is, of course, to foster thoughtful discussion on how technology can improve the care of older adults, from the perspective of clinicians with practical experience in providing health services to older adults.

2. Find a decent medication list application that I can recommend to patients and families. My biggest priority is that the app help patients keep track of *everything* that has prescribed by multiple providers, including hospitals and EDs. It also should list over-the-counter meds and supplements. (For more on why keeping track of medications is so important, see this post.)

– The must-have feature: medication entry (name and dosing instructions) that does NOT require laborious typing entry for most medications.

– Also required: app cannot be dependent on a single pharmacy chain or EMR system. Many of my patients change pharmacies or use multiple pharmacies. And most of them see providers in different health systems.

– Bonus points if it allows patients/providers to list the purpose of the medication — imagine if every patient understood the purpose of every medication prescribed to him or her!

– Additional bonus points if the app keeps a history, including discontinued medications.

Note that I’m not looking for this app to serve the function of daily reminder (in part because so many of my patients use medisets). This is a nice feature, but my greatest need is to quickly see what the patient is supposed to be taking. I also want to know what the patient is actually taking, but for that purpose, I prefer to see the bottles themselves and be able to use a tool to help with medication reconciliation.

3. Shorter blog posts. Time for me to get better about being concise. Well, for January at least.

There is of course much more that I hope to do and learn in 2013 (so many interesting changes and innovations, so little time), but as far as resolutions go, these three will have to do.

In a nutshell:

This year I resolve to score a clinician-written guest post, to find a medication app worthy of recommending to patients, and to write shorter blog posts (for at least a short while).

If you’ve come across a medication app that might meet my needs, please comment or email me.

Onwards!

Summarizing GeriTech in 2012

Today is not only the last day of 2012, but also marks the three month anniversary of the GeriTech blog. This is the 36th post, all written so far by your faithful practicing geriatrician (atypical practice, to be sure, but real practice nonetheless).

So it seems like a good time to look back at what’s been posted, and try to summarize what this blog is about.

I’ll admit that when I launched this blog, it wasn’t with the intention of being the sole author. I was rather looking forward to hearing about what technologies other clinicians had found to be helpful in the care of older adults.

However, so far the clinicians have been rather quiet on the blog (although they tell me very interesting things about technology when I talk to them in person, and I hope to get some of this on the blog in time).

For now, GeriTech = Leslie Kernisan’s professional interests, and hence reflects my personal priorities, interests, experiences, and discoveries about innovation and the future of healthcare.

Here’s what this specifically means:

Geritech is about addressing the nation’s most important healthcare question

No false modesty here! This blogger believes that her interests dovetail with the most important healthcare question facing the country, which is this:

How can we, as a society, provide effective compassionate healthcare to an aging population, at a financial cost that the nation can sustain?

(Do you disagree? Post a comment asap.)

Better primary care for older adults is the answer

The answer to the question above, of course, is that we must meaningfully improve primary care for older adults. This is a no-brainer conceptually. First of all, it’s what patients say they want: to receive care that is comprehensive, coordinated, person-centered, prevention-oriented, as upstream as feasible, and as outpatient as possible. Second, it’s what is cost-effective, compared to managing health problems later when they become health crises requiring hospital care.

(Again, if you disagree with the above, I’m eager to hear your case.)

Just about everything I’m professionally interested in tracks back to this essential issue: how to support and implement better primary care for older adults.

The problem is that it’s very hard to figure out just how to improve primary care for older adults. Still, it must be somehow done.

GeriTech’s key points and discoveries so far

All in the service of fostering better care for medically complex older adults, here’s what I’ve found myself saying on GeriTech:

  • Most tech tools seem poorly suited to improving the health care of older adults. As far as I can tell, most tools are not designed for use by clinicians caring for complex older patients with multiple medical problems. This is a big problem, as we really need effective tech tools that do one or more of the following: 
    • 1) help clinicians like me do our work better, faster, or more thoroughly; 
    • 2) help patients and families do their healthcare work better, faster, or more thoroughly; 
    • 3) support the collaboration between clinicians, patients, and caregivers. 

I posted a list of likely obstacles to senior health tech innovations here.

  • Effective tools for older adults should be developed with the help of practicing generalist clinicians and geriatricians, i.e. generalist clinicians who have real-world experience managing whole older patients, not just specific diseases. (For instance, I might say that I don’t particularly need continuous monitoring of blood electrolytes, but I do need help collecting data on symptoms.) We need the involvement of people who have experience with the space in which the rubber meets the road.
  • Patient engagement requires clinician engagement.  I believe that ideal health care is grounded in constructive collaborative relationships between patients, caregivers, and clinicians, in which clinicians serve as expert consultants in helping patients meet their healthcare goals. This means that solving for patient engagement means solving for clinician engagement.
  • We should rethink how we are trying to engage and motivate PCPs. Meaningfully improving healthcare for older adults in large part means helping PCPs change what they are doing. We will both need them to adopt new ways of practicing (including new technological tools), and we need many of them to change the way they engage and relate to patients, caregivers, and other clinicians. Also, most geriatric care will be delivered by PCPs (not nearly enough geriatricians to go around now, never mind in 20 years), so their working conditions should be of utmost interest to all those who want healthcare to get better. Right now I hear a lot of talk about incentivizing PCPs and tinkering with compensation. There is not nearly enough talk about nurturing clinicians’ internal motivation, and relieving their feelings of burnout. As a doctor who left conventional primary care practice due to burnout, I’m concerned. Smartphones and tablets alone will not help us care for our parents and grandparents, even if they have the world’s best computer algorithms behind them. We need clinicians to be ready and able to partner with us.

In a nutshell

This GeriTech blog is fundamentally about the pursuit of better healthcare for older adults, especially the frailer and more complex adults who have the most need (and who happen to be my patients). Improving primary care for this population is essential. We will need suitable tech tools and suitable systemic changes to achieve this.

Through this blog, I’ve been documenting the practical challenges that I find myself, my patients, and their families facing as we work together to improve their primary care. I hope that this information will help develop others develop better technological solutions, which can improve geriatric care.

Much of the ongoing conversation about improving healthcare doesn’t have nearly enough focus on the particular needs of older adults and their families, or on equipping the average PCP to handle those needs. Hopefully this will change soon.

The most pressing healthcare problem our society needs to solve asap is how provide effective compassionate care to an aging population. This blog will continue to encourage clinicians, innovators, developers, and thought leaders to work on this problem, with a special focus on how technology can be part of the solution(s).

TEDMED’s Chronic Diseases Videochat: Lots of Lifestyle, Minimum on Multimorbidity

Yesterday was the TEDMED Great Challenges virtual panel discussion on “Managing Chronic Diseases Better“. I listened and participated by Twitter. (See it here.)

I came out of the talk thinking they should rename their Great Challenge:

How Coaching and Lifestyle Modification Can Prevent Diabetes, Obesity, and Cancer, and Can Also Help Manage Diabetes. 

Because those were the main topics discussed, and also seemed to be the primary domain expertise of the Challenge Team.

Now, these are indeed worthy topics of great population health importance.

However, such a focus marginalizes the millions of Americans who need much more than coaching and lifestyle modification to manage their chronic diseases. It also offers little help to those of us — clinicians and caregivers — in the trenches who are struggling to help these patients with their complex health needs.

Another disappointment is that the discussion didn’t really address the challenges of managing multiple chronic diseases, also known as”multimorbidity”. This is unfortunate, since managing chronic diseases becomes a different — and harder — ball game when people have several of them. (Here’s one review of the evidence.)

This is especially true when people are older and frailer, or if they have cognitive impairment (which seriously impairs their ability to self-manage their chronic conditions).

And as any primary care provider can tell you, there are *lots* of people out there with multiple chronic diseases. The UpToDate chapter on multimorbidity (which relies in part on this report) lists the following fun facts:

  • Estimated 1 in 4 Americans have at least two chronic conditions
  • Estimated 2 in 3 Medicare beneficiaries aged 65+ have two or more chronic conditions, 
  • Estimated 1 in 3 Medicare patients has 4+ chronic conditions 

The UpToDate authors go on to say that:

“Multimorbidity is associated with staggering healthcare utilization and costs. The two-thirds of Medicare beneficiaries with multimorbidity account for 96 percent of Medicare expenditures.”

Doesn’t this sound like a Great Challenge to you?

Well, it seems this is not the Great Challenge TEDMED has in mind. This Great Challenges team was very strong on prevention and lifestyle modification, had a strong patient advocate (a younger woman with Type I DM), but had precious little advice on managing scenarios like the one I describe in this post.

What to do when a person with diabetes, high blood pressure, arthritis, glaucoma, and eleven
medications comes to the visit, where we discover uncontrolled blood sugar, too
high blood pressure, falls, urinary frequency, anxiety, trouble managing
medications, and social isolation?

This is managing chronic diseases as many of us experience it. We could use more innovative brainstorming sessions to work on solutions.

The TEDMED panel on the question I didn’t ask

Here is a question that was mistakenly attributed to me — in a twist of cosmic irony, TEDMED identified me as the author of a question that I would literally *never* ask —  followed by the initial answer provided by Dr. Micheal Roizen, Cleveland Clinic’s Chief Wellness Officer:

Q: “What do I do with patients who are resistant to any kind of help with their chronic illnesses, and with behavior change related to that? How do we convince patients who are resistant to treating his or her chronic disease?”

A: “The only ways are either educating them about what is important, or incentivizing them strongly.” (See the rest of the answer here; the details include coaching, environment modification — get the Chips Ahoy out of the room — and a nice $2000 bonus for those patients who succeed).

Dr. Roizen goes on to say that 63% of their patients with chronic disease have transformed. This is a nice result. But I doubt you’d make much headway using that approach with older patients suffering from multimorbidity.

Why? Let me start by answering the question that I didn’t ask.

What, in fact, do clinicians like me do when we come across older patients who are “resistant to help with their chronic illnesses”? Here’s what I do:

  1. Assess for cognitive impairment. Before I start “educating”, I look into underlying reasons for why the person can’t manage their health care, or otherwise isn’t following through on the care plan. In older adults, cognitive impairment is often discovered, once one looks. (Early dementia and medication side-effects are the most common underlying problems that I find in the outpatient setting.)
  1. Try to figure out how the patient and family see the illnesses, in order to understand what’s interfering with their ability to address the illnesses. Common things that turn up include:
    1. Financial problems getting the medications
    2. Overwhelmed by too many medications, by too much complex medical care in general, or by caregiving demands
    3. Skepticism about allopathic medicine or other doubts about our conventional proposed approach
    4. Misunderstanding how serious the illness is, or how treatable it might be
    5. Substance (ab)use
    6. Low health literacy

You’ll notice that many of the problems above are far more common in people with multiple chronic illnesses.

Now, I’m not against lifestyle changes and behavior modification. My goal, and I know this is the goal of many PCPs and geriatricians, is to figure out a mutually agreeable, and feasible, plan to help the patient with his or her health. Often this includes coaching on lifestyle (if I can help them get it) or environmental modification (if feasible). 

But a lot of it is figuring how to help patients follow-through on conventional medical management. Like picking one or two generic medications to focus on (a good opportunity to talk about what’s likely to bring the patient the most bang for their buck). Or picking a symptom to focus on managing. Or sitting together to review what the specialist said, and putting it in light of the patient’s overall health condition (and other chronic diseases).

The TEDMED panel on geriatrics and chronic disease

Another illuminating question and answer: here is the geriatrics-related question I had submitted via Twitter:

My Q: “So much chronic disease occurs in geriatric patients. Why aren’t there more resources targeted especially towards the elderly, or those with dementia?”

The question was directed to Dr. Dileep Bal, a public health officer from Hawaii, and you can view Dr. Bal’s answering the question here.

He gives a long detailed answer focusing on — surprise surprise — prevention and wellness. He says the “focus needs to be in keeping them well, especially for elderly
population. Fifty percent of our health costs are related to people in
their last year of life. So I think both from a financial, and from a
lifestyle point of view, specially for the elderly, you need to focus on
how do you keep them healthy.”

He also says “Keep the well elderly well at home, before they show up in my clinic.” He goes on to describe a program of preventive care including senior centers, exercise programs, and systemic dietary interventions (like limiting soda and fast food availability). He mentions people in their 90s participating in exercise programs, and the need to modify societal cues (McDonalds is mentioned).

Another physician on the panel, Dr. Deneen Vojta (whose bio highlights extensive experience in diabetes prevention and management) offered a different perspective. She noted that older women commonly do not list exercise and healthy eating as priorities, but rather care about their finances, friends and family, and staying in their home.

True that! Then Dr. Vojta goes on to describe how lifestyle changes should be framed as ways to achieve those above priorities. She doesn’t address how patients suffering from very symptomatic chronic conditions, such as heart failure and COPD, can be supported in making these lifestyle changes (hint: for many, it requires medication optimization so they can be more active).

Sickcare versus health education and coaching

One part of the talk that did resonate with me was when Amy Tenderich pointed out that as our healthcare system is really a “sickcare” system, it’s problematic to ask it to be responsible for prevention. She suggested that we might consider adding another arm to the system, which would focus on health education and coaching.

I like this idea. However, for those patients who are older and sicker, education and coaching needs to really integrate into their “sickcare,” both by helping patients navigate the sickcare system, and by taking their various diseases into account when providing health education and coaching.

For instance, I’ve seen many older diabetic patients develop mild dementia, and struggle with their diabetes care. They need help figuring out simpler and safer strategies for their diabetes. However, many diabetes educators don’t seem prepared to problem-solve around mild dementia. (Or perhaps they just don’t notice my writing “suspect mild dementia” in the referral? Would earlier definite diagnosis via brain scan help?)

Is TEDMED’s panel missing a key point of view?

I found myself wishing TEDMED had included an expert able to really discuss managing multiple chronic diseases in primary care, such as Ed Wagner, who pioneered the Chronic Care Model. (This commentary by Wagner on chronic care management addresses multimorbidity and person-centered care, and is a really fantastic read for those who have journal access.)

They could’ve also considered someone particularly focused on the unique needs of older adults. I might nominate someone like Cynthia Boyd, a geriatrician who has published fantastic articles on multimorbidity and on Guided Care, a program
that help older adults manage and coordinate the care of their many chronic conditions. (Her 2005 JAMA article on what happens when you try to apply clinical practice guidelines to a typical patient with multiple conditions is a classic. She also co-authored this very good 2012 JAMA commentary on designing healthcare for multimorbidity.)

Last but not least, although I’m disappointed in the way that the TEDMED talk skewed towards prevention and lifestyle, I can’t say that I’m surprised. Much of what I’ve come across these past few months, as I’ve been learning about healthcare innovation, is skewed towards younger, educated people who either want to prevent disease, or are heavily invested in the management of one particular disease.

This despite the fact that the experiences of older adults drive most healthcare spending, not to mention the impacts on these patients and their families.

In a nutshell

Older adults and those with multiple chronic illnesses are two very large, important, and challenging populations to care for. Improving chronic disease management for these groups is essential, both for the sake of the millions of patients and families affected, and because this group drives the bulk of national healthcare spending.

TEDMED’s team for “Managing Chronic Diseases Better” seems to have special depth and expertise in the prevention of chronic disease. Their recent videochat largely focused on healthier lifestyles, coaching, and prevention, and had very little on the crucial challenges associated with managing — not just preventing — multiple chronic illnesses. They also had little to say about the ways that chronic disease management often should change to meet the unique needs of older adults and their caregivers (such as adaptations when patients develop cognitive impairment). Conditions such as heart failure and COPD weren’t discussed.

I’ll end by quoting the intro to the 2012 JAMA commentary cited above:

“The most common chronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions.”

If TEDMED wants its Great Challenge to be relevant to really making management of chronic diseases better, I hope they will find a way to address older adults and multimorbidity in future events.

For more of my take on TEDMED’s Great Challenges so far, see this post about the Great Challenges overall, and this post about last month’s videochat on caregiving.

Improving health information exchange from hospitals to outpatient

In my last post, I described why it took me almost two hours to sort through the recent hospital records of an elderly patient. The records had arrived in my digital fax queue as a PDF with 159 pages of images of text.

It seems a bit nutty, in this digital age, that so much of medicine is still being done through paper and faxes, but there it is. Most hospitals have EMR systems, but if a clinician who’s not within the hospital system needs medical information, that information usually gets printed and faxed. (At my previous job, I used to get CDs with PDFs from Kaiser. Better in some ways, but still relatively slow to work through.)

What might work better? The most popular plan I hear to solve the problem of independent clinicians accessing hospital records is to create Health Information Exchanges (HIEs).

I really don’t know what to think of HIEs, especially since I haven’t yet had the chance to use one.  They seem to be slow to set up — the Bay Area has been working on one for a while — and it’s unclear how well they will smooth the workflow of independent outpatient doctors.

Health Information Exchange features we need

Let’s assume the HIEs will eventually arrive. How should they function, to allow outpatient clinicians to get needed information in an easy and low-hassle manner? The best-case scenario I can envision with a HIE would be a online system that I could easily log into, and that would allow me to do the following:

  • Allow me to search through records to find specific items related to my patient.  I can’t emphasize search enough. Browsing seems to be the main EMR paradigm. It’s slow and a pain and increasingly divorced from our experiences with consumer software, where using the search function rules (and delivers). As clinicians, we shouldn’t be trying to figure out which section of some other medical center’s EMR contains pulmonary function tests; we should just be able to search for it.
  • Make it easy to copy certain records to my own EMR. The ideal would be to easily tag items that you want to copy, and then have them transfer to your own EMR with useful titles included. (Of course, if the data I get is searchable and my own EMR has a good search function, the titles become less necessary.) An alternative would be for providers to be able to use something similar to the EverNote web clipper tool, where you highlight what you want and it gets easily transferred.
  • Push or pull certain commonly requested groups of records on request. Just as most labs have created groups of commonly ordered labs (CBC, comprehensive metabolic panel, etc), you could create groups of commonly requested records for certain purposes. For example, when I need to review records from a hospitalization, I want to see the Admission H&P, the discharge summary, all radiology (except chest xrays; just one of those please) and studies, and the last available lab values. (I don’t need every CBC drawn in the hospital, just the last one.) Ideally providers could customize the groupings that they wanted. The consumer version of this is creating a search/query, and easily being able to save/reuse it.
  • Lets the patient directly give me permission to access his/her records. Whether
    or not the patient gets direct access to all his or her hospital
    records, wouldn’t it be great if the patient could directly and easily
    give permission for certain clinicians to gain access? Would speed
    things up immensely, and make it easier for patients to make sure their
    care is coordinated. 


What’s the best path forward for information sharing and care coordination?

I admit I’ll be surprised — stunned, really — if the HIE, whenever it finally arrives to the hospitals near me, has many of the above features. An HIE is after all enterprise software, purchased not by the daily users, but by administrators or better yet, groups of stakeholders.

Are there alternatives? Some EMR companies, like Practice Fusion, are spearheading a move towards peer-to-peer sharing of medical information. This is a promising idea, but doesn’t help when one is trying to extract information from a hospital.

Another option: that health information sharing among clinicians will be driven by the patient’s control over his or her medical records. Certainly could happen, since connectivity with patients may happen a lot faster than PCP connectivity with hospitals.

Personally I’d welcome this, as I’d like to see patients get to gatekeep most of their medical data, including laboratory data. But I don’t know how close we are to patients getting access to their raw hospital data (and am skeptical that the Blue Button output would cut it, when it comes to clinicians getting the needed info to coordinate care). OpenNotes is a promising start but was just for the outpatient setting — and the patients were mainly in their mid 50s with relatively few medical encounters.

Will patients soon be able to download meaningful hospital data into their personal health records (PHRs) and share with clinicians of their choosing? Only if they demand it.

In a nutshell:

Health information exchanges (HIEs) are projected to eventually allow outside PCPs to access hospital records. Features I hope they’ll include are capacity to easily search and copy the information. Bonus if patients end up able to directly give other clinicians permission to access their medical information.

For more information: in doing a little brief research related to this post, I came across a few good resources for those who want to learn more about HIEs. The National eHealth Collaborative has a report on “Secrets of HIE Success,” which offers insights into how some HIEs have come into being.

But far more interesting and informative to me is Robert Rowley‘s series of blog posts on HIPAA and HIE: Part 1, part 2, part 3, and part 4. Love it when articulate primary care docs write about healthcare.

Clinicians and others, have you had good experiences with HIEs yet?

Flawed tech & processes hinder care coordination; why reviewing a hospitalization took me two hours

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.