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From the Sublime to the Ridiculous

From the sublime to the ridiculous.

That’s sort of how my day went yesterday.

It started out with an early morning meeting with a colleague who has been implementing a telehealth program at one of our institution’s practices, learning about how they have been using this technology, some of the bumps in the road they’d hit, and how they’d been able to turn it into something that is actually taking really good care of patients.

They’d developed the infrastructure, trained a whole team of staff members to help appropriately triage cases, and assigned a group of practitioners to take shifts to handle these video visits.

We walked away from the meeting impressed by what they had done, hoping to figure out how to make this work in our practice, while certainly recognizing some of the restrictions and limitations that we know are going to pop up as we try to implement this new technology, this new way of taking care of patients.

So the morning started out with a little gee-whiz, high-tech, linked up cell phones and video monitors, and a new way of taking care of patients.

My day ended with a much more low-tech, old way of doing things, that I somehow can’t believe we are still doing.

This involved a visit that I was having with a physician for a semi-acute medical condition.

Since I am enrolled in our EHR’s patient portal, I got an email from his practice 48 hours in advance alerting me that it was time to start my e-check-in process.

Once I got through the username, password, and security question, all of which had expired and needed to be reset (I don’t go to the doctor very much, most physicians are terrible patients, but that’s a story for another day), the system walked me through the multistep process for advance check-in.

I updated and confirmed my name, address, date of birth, phone numbers and email, emergency contacts, insurance.

Another screen listed my current medications culled from the electronic health record and asked me to confirm those I was taking, discontinue those that were old and no longer active, and add any new ones that may have been put on by another provider outside the system.

Then click here to confirm the changes and certify that my medication list was reconciled and correct.

A few more fields, a few more questions to answer, and then I was done, and they sent me a happy notice saying I had successfully e-registered.

Yesterday, when I arrived for my appointment, I was greeted at the front desk, asked who I was there to see, and then I was handed something that I thought we’d obviated the need for.

A plastic clipboard with a five-page form paper on it.

Although I didn’t want to be one of those annoying patients who questions everything that happens to them at the doctor’s office, I mentioned that I was already in their electronic health record and that I’d completed successfully their own electronic pre-registration check-in process.

The front desk support staff advised me that I needed to fill out the form.

Again, not wanting to be a difficult patient, I sat down in their waiting room and began to fill out those five pages.

Name, date of birth, address, cell phone number, home phone number, work phone number, fax number (really?), referring physician, primary care physician, reason for visit today, insurance carrier, insurance ID, insurance group plan number, pharmacy name, pharmacy phone number, pharmacy fax number.

Allergies, surgical history, family history, smoke, drink, drugs.

Then it asked for a list of medications, dosages, and how I take them.

I was struck that now I’m sitting there in the waiting room having to hand write the names of all my medicines, the dosages, and how often I take them, but isn’t all of this right there in the computer in front of them?

If it exists electronically, then asking for it yet again seems so redundant and certainly a recipe for mistakes to happen.

The last few pages asked a thorough past medical history (also already updated in my chart), as well as an incredibly elaborate detailed review of systems, which certainly seem like something relevant to those taking care of me today.

Being relatively healthy, there were only a few things I had to check off, and once I was done I handed the form into the registration staff at the front desk like a good patient.

Now I wonder, whatever became of this paper, did this help someone take care of me, did this change my care, or improve my care, or make it safer?

Once I was taken into the exam room, the provider assisting my physician asked me about my current symptoms, asked me if I was allergic to any medicines, went over my medication list in the computer (not off the form) which had been updated by me in the computer already.

She then did the test which had been ordered before the visit by the physician, and then left me alone to wait.

Somewhere out there in the office was that paper form, those five pages I’d handwritten all that useful stuff on, but they never really seemed to enter into the care process of my visit.

I can certainly see the benefit of these sorts of forms for a new patient who is not in the system already, if that person who is putting me in the room takes the form and goes over it with me and enters it all into the computer.

But since we’ve built all of this electronic functionality into the medical record, why are we still using paper forms?

By now, for most patients, somewhere in the world someone has clicked “No Known Drug Allergies” in some electronic health record, or clicked “Penicillin” and the description “caused a rash when they were a child.”

Somewhere out in the world, the prescription for a proton pump inhibitor, a statin, a diuretic were attached to that patient, indelibly linked to them, and should be captureable and translatable and brought into the system that we’re using no matter where it is, no matter who owns that software.

As we move towards a high-tech world of video visits and remote monitoring, with artificial intelligence systems trolling through our electronic health records to tease out hidden pearls that will help us take better care of our patients, and intelligent systems that recommend the best care based on all of the data we have at our disposal, why are we asking patients to rewrite their medications by hand?

Perhaps it’s time we insist that the people who are making these systems, who are supplying them to us and charging us an enormous amount of money get over themselves and get over their fear of patent infringement or whatever it is that’s keeping them from really solving the interoperability barriers that they seem to say are just too great to overcome.

Right now, there are parts of this that seem to be working their way into the system, and they prove to be quite useful.

When my patient has a flu shot at their local pharmacy, this info gets channeled to my electronic health record and I can see it in the immunization registry, and as an outside message that sends a PDF of the form filled out at the pharmacy with the lot number and dosage, and even on the medication reconciliation section where I can see the date that it was prescribed.

And sometimes patients come to us and can’t remember what medicines they take but when I click on the medications section of my electronic health record, I can see a medication history that’s hidden in the background behind a gauzy veil.

Wait, I tell them, it says here you filled an SSRI, a statin, a diuretic, a beta blocker, and a benzodiazepine, all in the past three months.

If we are going to build 21st-century practices, we need to make sure that everything that happens to our patients gets brought to us so that we are aware of what’s happened and we can safely take care of them as efficiently as possible.

We all want all of the visits that all of our patients have with all of the other doctors and other providers out there to come to us so we can see what’s going on.

Every time our patients touch the healthcare system or the healthcare system touches them, we should know about it, and have it made available to us to synthesize and incorporate so we don’t need to keep re-creating the wheel.

So we can keep working on the bells and whistles, building remote monitoring, embedded sensors, digital health, telehealth, virtual visits, whatever the care of tomorrow will look like.

But in the end, if we’re asking patients to write a bunch of stuff down, and then we’re not even copying it into the chart, maybe we need to rethink how we do things, to build that better healthcare system we all need and want.