AttendingDocNJ

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May 25, 2016
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A snapshot of a doctor in his daily clinic:

Imagine a typical clinic day: You have a new patient in your clinic who was admitted recently to the observation unit at a local hospital for “high uncontrolled glucose levels” and discharged one week ago. Patient has not brought his discharge summary to your clinic and the hospital is not affiliated with your outside practice. The patient has poor medical insight but states that he has had “ton of usual medical problems” in the past. Patient states that he hasn’t seen a primary care physician in ages and he frequents urgent care centers or ERs when he needs refills of his medications. You quickly get a patient’s signature for a medical release form to be faxed over to the hospital and you ask the patient for the name of the pharmacy where he gets his medications.

Because the patient is new to your practice, you decide to order a basic metabolic panel, complete blood count, a fasting lipid panel, and HbA1c as no outpatient laboratory studies are found in Labcorp [or your local laboratory services provider]. Patient also adds that he has been experiencing productive cough with sputum on and off for the last 3 months after traveling to Southeast Asia. You are aware that the medical records from the hospital will take at least few hours to a day to come back and so, you order a chest x-ray PA/lateral given the concern for possible TB and a HIV test given the clinical history.

The next day, all the hospital results come through the fax and BMP/CBC is normal with HbA1c being 7.8. Also, the hospital had ordered CXR (PA/Lateral) which was unremarkable and also done an HIV test which was negative. The labs you ordered also come back with similar results. You look through the hospital discharge summary and find that the patient was admitted into another hospital 2 weeks before this one for similar clinical presentation for high blood glucose levels. Unfortunately, each hospital discharge has prescribed a different sulfonylurea and upon calling the patient, you find that patient has been taking 2 different sulfonylureas from 2 different pharmacies.

This fictional snapshot of a patient scenario is a reality that primary care doctors face every single day in which duplicating imaging and laboratory studies are done on frequent basis. The problem is only compounded when patients have multitude of different specialists who communicate via fax but order different dosages of medications for the patient or take out or add medications without the knowledge by the other doctors. Unfortunately, our current methodology of such practices has contributed significantly to the rising costs of insurance premiums and creates about loss of 20 billion dollars in health costs every year. This problem is even further exacerbated in areas of population who lack healthcare insurance as these people utilize ERs for management of routine problems and refill of medications which can be readily handled by an outpatient clinic. If you add to this mix the patients who lack medical insight as our fictional patient above, it is not surprising that our national healthcare system is a challenging and an hot-button issue.

What is a solution that we can take as doctors? We can ask for an integrative Electronic Health Record [EHR] system in which all the hospitals and outpatient doctors’ offices are connected through one single system statewide. Currently, many states in the country have Health Information Exchanges set up in local region of network hospitals which is allowing safe exchange of patient data and reduction in repetitive studies especially CT-scans. A study published by Stanford Medicine in January of 2014 showed that in the states of Florida and California who were early-adopters of Health Information Exchanges, “patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].”

The main argument against integrative EHR so far has been the costs of implementation and patient confidentiality. However, as physicians, our current hospital-limited EHRs can be accessed readily through phones, tablets, and laptops and it is up to us to have the ethical and legal responsibility to not openly access or share patient information outside of medical jurisdictions and indications. As for the financial implication of an EHR, it is important to compare the prospective costs of efficient healthcare delivery through statewide exchange of patient information against our current norm and it is in plain sight that EHR would be a fiscally-responsible initiative.

If a vision of integrative EHR is realized across the nation with focus on patient safety and confidentiality, we can truly achieve breakthroughs in cost savings and deliver healthcare in a timely manner without depending on a fax machine as a main tool of communication amongst providers. These are the real costs that are draining our healthcare system and need to be at the forefront of any discussion about healthcare. Politics and different bills spearheaded by legislative process won’t solve this issue whether it is Obamacare or Trumpcare but right and meaningful implementation of technology will aid us in providing optimum care to our patients and easing the burden on our healthcare system.
 
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IM2GI

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Dec 5, 2013
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EHR is huge business and the market is extremely fragmented. The players are not going to go quietly. Even a small piece of the pie is extremely valuable. Pretty much an impossibility in the United States to pull this off.

Your best bet is getting the biggest players to talk to each other, which Epic and Cerner kind of can, although the integration is painful.

Also, the privacy concern is real. Every year some huge corporation gets hacked be it Home Depot or Target or Sony, with data and credit card info stolen.
 

Psai

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We should just all move to epic. Getting outside records is such a hassle. The people working in medical records seem to earn a bonus every time they deny a patient's medical information to a doctor and by the time you finally fax over the 5 different forms they demand, they frequently leave out the thing you're looking for.
 
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VA Hopeful Dr

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We should just all move to epic. Getting outside records is such a hassle. The people working in medical records seem to earn a bonus every time they deny a patient's medical information to a doctor and by the time you finally fax over the 5 different forms they demand, they frequently leave out the thing you're looking for.
The easiest fix that I've come up with over the years is that it should be very easy for a local physician to get read only EMR access at every hospital in town. There should be a special level of privileges where all you have to do is sign a HIPAA form and prove you're a licensed physician in the area to get read-only access. That would solve 99% of these types of problems.
 

xoggyux

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I feel the problem runs way deeper than that. Yes I do agree the EMR situation is awful, specially considering modern era technology. If a medical database standard existed one that is secured and shared among different EMR/Hospital Systems/Lab corporations, imagine what that could do for us physicians and for our patients. A system could exist whereby our patients could sync their electronic devices (smartphones/watches/etc) on every visit and have a permanent, uptodate copy of their whole records. Furthermore, this could even happen automatically under the right conditions. Without having to sign a billion papers that nobody will ever read. Imagine how nice would it be for us to automatically get in the clinic every single lab test done on the hospital, every single note written and perhaps even nurses notes, imagine knowing exactly when and where the vaccinations of our patients received and whether the consultants (OBGYN, Cardiology, nephrology, etc) had ordered labs, adjusted medications or ordered imaging. This in combination with the now emerging "health" oriented devices and apps could make for a significant improvement on the quality of care we can offer to our patients. But this is wishful thinking, and despite me being in the very beginning of my career, I am not too hopeful that I will see anything like this anytime soon.
Healthcare is a business, in fact is THE BUSINESS. This means the industry is plagued by mechanic and logistical features which main goal is to optimize cashflow, in this scenario patient care takes a secondary role. This means a company will rather keep their EMR solutions patented and secret rather than share with other companies and improve the overall system (i.e. all EMRs in this example). A company will rather price this fantastic new antibiotic for $700 USD a pill when the manufacturing cost is pennies (yes I know this might be an overly simplistic view that does not take into account research and development, advertisement, testing, liability from possible class auction suit because of side effects, etc. However, the reality is that drug manufacturers make billions in profit and their CEOs make millions in bonus, they are not exactly struggling entrepreneurs).
Finally I think that our culture of litigation, specially in the US, is one of the biggest, if not the biggest, contributor to the huge cost of healthcare. Expensive malpractice insurance, and the fear of just every single doctor about missing something. Does this sound familiar? Patient John Smith, well known to the hospital staff, 40 years old male alcoholic. Has been brought to the ED 20 times in the last year by the police/firefighters because was found unconscious sleeping on the street. In the E.D. the Dr, who knows him very well because he himself has admitted John about 10 times prior, knows that his sole problem is alcohol intoxication but because he was unconscious and because he babbled something about pain in his chest area at some point during the ambulance transport has to do a full ACS workup and a CT scan of the brain, CXR for aspiration, and IV Rocephin/Vancomycin just in case in addition to the DT/alcoholic protocols. Yes the Dr. in the ED could use his judgement and say, wait a minute we don't need this and that it does not make sense but he is scared to death of missing that 1 in a billion chance and ruin his career because he missed something. I completely understand this fictional doctor (who represents many of us on different situations). But it is wrong nonetheless and the more we do it the more resistant we are to sensible change.
 

gutonc

No Meat, No Treat
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Holy crap...you need a Return key and some Ativan.
 
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AttendingDocNJ

2+ Year Member
May 25, 2016
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Attending Physician
Great post Xoggyux! Pretty much summarizes how I feel about the current situation.
 
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