OPINION – December 20, 2012 -- In a pre-health reform world without interoperable electronic health records (EHR), or a patient-centered provider collaborative model, my healthcare experiences over the last year or so are all too common. As a biomedical informatician and healthcare attorney, I will set forth this experience in this article, and then offer some initial thoughts on how interoperable EHRs, and a patient-centered provider collaborative model can afford a greater quality of care, in a more cost-effective manner, with less angst and less time on the part of a patient. A series of subsequent articles will address the specific principles that might improve the quality of care in a more cost-effective manner.
Complaining of an ear ache, I visited my primary care physician (PCP), an internist, who practices on his own in a suite with other sole practitioners sharing costs of the suite. Upon entering his office, you can see the very many paper records on shelves. The records have been there for years. He has been contacted by the local hospital's medical foundation about working for it. The foundation would kindly provide two medical assistants for him, and reduce the amount of time he would "have to spend" with each patient.
After a series of questions, and a brief examination, the diagnosis was an ear infection and an antibiotic was prescribed. The PCP E-prescribed the antibiotic, noting that it would be available at the pharmacy down the street from my office. It was there as promised, and I paid the co-pay after strolling through the many aisles of the national chain with all of its non-prescription drugs, sundries and food and candy offerings.
For a while the antibiotic seemed to help, but alas, it did not appear to definitively resolve the problem. Another visit brought the suggestion, let's wait and watch. Unfortunately, wait and watch was not the cure. The result was a referral to an otolaryngologist (ear doctor), in a relatively large single-specialty group (a practice of physicians of a similar specialty). When I arrived at the ear doctor's office, I was immediately asked for my health insurance card, and provided with a form to complete background information, and my complaints. After a while, I was taken beyond the waiting room. I could not help but notice all the rooms and the equipment that was present in them. I thought all of these services were previously probably primarily offered at the local hospital, but physicians, particularly specialty physicians have been trying for years to supplement their professional service incomes with facility type services.
Upon walking into the ear doctor's examination room, I notice he was wearing some type of head gear that looked somewhat like that of an air traffic controller. He had a head set with a microphone and he would query me about my complaints, and then he would push a button in the ear of the head set and repeat what I said. Somewhat confounded as to how long this was taking and how non-patient friendly the experience was, I asked what he was trying to do. He asked me to repeat my complaint and added a correction. He said he was dictating using a voice recognition software which would make it easier for him to transcribe my medical record. and he would not have to stay later at night to complete his records.
After an initial examination, I was asked about my health insurance. Once it seemed to be of the office staff's likening, I was ushered into a series of rooms for many tests. I remarked that when I was going to the audiologist's room, I would not have the best hearing because of the fact that many years ago I had managed an unsuccessful rock band in Southeast Asia. My prediction about the results of the test was correct. A culture was taken during the scope of the overall examination process, and sent to a lab. I do not know whether this lab was owned by the ear doctor, other clinicians, the local hospital, or a national lab company. All I know is sometime later I was advised thankfully, that it was negative.
After the battery of tests, the ear doctor noted that I might have referent pain (that is pain emanating from one area, but evidencing the pain in another). He then asked whether I had pain in my head and neck. He said if I did, he could order an MRI (magnetic resonance imaging) scan of my neck. I said that I did, and thought I had mentioned this earlier, but perhaps it was lost in the voice recognition software. An MRI was ordered. I was told that I could go to a place that would be less expensive. Upon reflection, I do not know whether it was supposed to be less expensive for me, the insurer, or society. I understood the MRI to be owned by an investor-owned (for profit) group, but I do not know whether it was owned by the ear doctor, his colleagues, other clinicians, a local or national investor-owned concern.
It took just a short while to get the MRI appointment. When I arrived at the facility, I was asked about payment, and recall providing a credit card, and then promptly brought in for the MRI. It seemed to me that the facility may have been underutilized. After the MRI, and upon checking out, I was given a large amount of very large films in an envelope. I was perplexed: why were these films not digital? Why was I being given them, and why were they not being electronically sent to my clinicians' offices? I advised that the films were unacceptable to me. Eventually, many days later, I received the films on a CD which I had to forward to my clinician's office. After what I believe was a review by my PCP and ear doctor, I visited my PCP again, who referred me to a neurosurgeon.
I was told that this was one of the best neurosurgeons not at the University Hospital. I queried why I could not just go to the University physician first, and was advised that generally folks visit him after they have been to another neurosurgeon. This neurosurgeon was not affiliated with the same hospital as the first two clinicians. When his paperwork arrived, it became clear that he worked for a hospital medical foundation. It was very difficult getting an appointment with him. When I finally did get to visit with him, he did not have the MRI. Fortunately, I brought the CD. I thought that if he had an EHR with the MRI, he could have reviewed it before I visited his office.
Some of the insurance details this time were addressed prior to the visit, along with the next form asking about background and my complaints. Interesting, upon entering the neurosurgeon's office, I saw on his computer what seemed to be an EHR. He said he was forced to use it, but it did not work well for him. I asked him what he did not like about it. He mentioned a number of icon issues and placement of certain information. Since the neurosurgeon's EHR was not interoperable in the context of my MRI, he loaded the CD and provided a diagnosis, and prescribed physical therapy. I suggested some changes to his initial EHR screen using some human computer interaction (HCI) ideas which might make his EHR work better for him. He thanked me and a computer generated script for the physical therapy was faxed to my office.
After some time, I arranged a few physical therapy appointments at the physical therapy department of the hospital to which the first two clinicians were affiliated (or on the medical staff). Of course, I was first asked for my health insurance card, and given a form to fill out about background information, history and complaints. I thought why could not the information in these forms be in some electronic form, to enable all the clinicians, the MRI facility and the physical therapy facility to have them, with my only having to complete them over and over again. As best I tried to complete each successive form in the same manner, I wonder whether I had. By this time, when I went back to the physical therapist, I asked whether she had reviewed my MRI, and she said she did not have it. I thought how odd. It is 2012 – the age of EHR. She asked me a number of questions. I wondered whether she would have had to ask me all these questions if she had reviewed the MRI. She asked me to bring the MRI CD to my next visit. I did bring the MRI on a subsequent visit, and also mentioned that I had penned an article on "Accountable Care," that was soon thereafter cited in a brief to a state supreme court. She seemed disinterested in the article and my thoughts on health reform and the changes in the healthcare system. Well, I brought the article anyway. She never referred to it.
I started to respond somewhat to the physical therapy, but moved to the lovely city of Portland during the middle of my therapy and have not been able to resume it. I would like to. If I could just go to a physician therapist’s office and continue therapy that could be easy. I fear no one would have my MRI, the record of my background information, my complaints, the nature and extent of the therapy I had. This lack of fully interoperable EHRs without a clinical decision support systems (CDSS), computerized physician order entry (CPOE), in a fragmented healthcare system, which is not patient-centered and without a cross-collaborative team model may just have worn this biomedical informatician attorney out.
Other interesting interfaces with the healthcare system during this time included a visit to my ophthalmologist where I had a series of many more tests, but this time on my eyes. Toward what appeared to be the end of my eye appointment, I asked when I was going to get to see the optometrist to have my reading glass prescription checked. I was told that no one knew I wanted this type of eye test. I had no idea how anyone could think anything differently, but what would I know, I was only a patient. I was told that since my eyes had been dilated, I would have to make a subsequent appointment, which I had no choice to make. I was struck by the large number of testing rooms with much equipment in the eye doctor's office akin to that of the ear doctor. I also could not help but notice all the very nice looking eyeglass frames that the office had available for sale, no doubt another money making activity.
During the time of these many clinician visits, I was told that I could no longer fill my normal prescriptions at my local national pharmaceutical chain. Unfortunately, it had been unable to reach an agreement with the pharmacy benefit manager (PBM) to which it had a previous arrangement. I took this as somewhat as a positive, affording me the opportunity to switch to a locally-owned pharmacy. (I thought “buy local.”) The experience, however, was less than desirable. There was a few days wait for some of the prescriptions and not all the pills were in each bottle. I was told that they would come along later. I actually had to go to that pharmacy two or three times. My assistant did a search on the internet and ascertained that this local pharmacy was not thought of highly. I switched to another local pharmacy. The experience was better, but I soon realized why the national pharmacy chains were so successful. They often are accurate, quick and provide great service, once you get past the nonprescription drugs, sundries and food items. When an agreement was finally reached with the PBM, I went back to the original national pharmaceutical chain.
Does this series of patient interactions sound similar to yours? Did you ever wonder whether the experience could be improved?
My next and subsequent articles will address some of the things that the principles of biomedical informatics in a fully interoperable EHR world with CDSS, CPOE, E prescribing, with a lack of fragmentation, in a patient-centered model could make the experience result in a better quality of care in a more cost-effective manner with a better patient experience.
Paul R. DeMuro is a National Library of Medicine post-doctoral fellow in the PhD program in Biomedical Informatics at the Oregon Health & Science University School of Medicine Department of Medical Informatics and Clinical Epidemiology, Clinical Informatics track and Special Counsel, Schwabe, Williamson & Wyatt, Portland, OR.
E-Mail: demuro@ohsu or [email protected]
