When I think about how hard it is to take care of our patients, and how many different people are involved in their care, it’s a wonder that anything ever gets done.
We need to simplify systems, and harness the power of the information systems available to us, as well as the promise of the electronic medical record, to improve the lives of our patients, as well as make all of our lives, all of our jobs, a little bit easier.
This morning we got a stack of paperwork on a patient who is followed in our practice, who really only comes to see us to get his home care forms completed. He sees multiple other specialists who are in our institution, who care for the various diseases and complications he has that require their particular expertise.
Not only did we have to sign one of those endless home care forms that listed dozens and dozens of goals that they said that the patient would achieve by being under their care, but we also had to fill out page after page of documentation for the durable medical equipment this patient requires.
Noted on their faxed request along with the forms was the statement, “You must include the last five progress notes” for the patient to be able to receive both his ongoing home care and the durable medical equipment necessary to safely take care of him in his home.
How did that become a rule? Who interpreted some regulation or guideline somewhere that said five different (potentially not very useful) progress notes must be included with each request for durable medical equipment?
This particular patient has a serious chronic condition (one that unfortunately will never “go away”) that has left him completely dependent on others and with many of the complications that can arise from this condition.
To better take care of him, we need to figure out a better way to collaborate, to share the responsibility, to make sure he gets what he needs, to do what’s right.
One of the requests was that we order some specialized catheters for him, and they told us we needed to give them all the details of the type of catheter, how they were used, and what supplies were needed to allow the home care nurses to safely insert them.
Unfortunately, we internists are not in the catheter business.
His urologist knows best which catheter he needs, and as far as we can tell, it’s probably been the same catheter he’s been using for the past 15 to 20 years.
Why does the durable medical equipment company suddenly not remember what he got last month, and instead makes us do what may be a significant amount of work just to get this patient what he needs?
There’s got to be a better way.
As our institution moves towards a unified electronic medical record across its entirety, we have broken up into silos that look at how each different practice, from pediatrics, to surgery, to OB/GYN, to emergency medicine, all use the electronic medical record differently, and the EHR team has been seeking our opinions about what we need to optimize it, to take care of our patients.
During yesterday’s meeting, we were going over several forms that people have used or developed that they would love to have built into the system, to make their lives better.
One of these was a form that is sent to the primary care provider when a patient is undergoing bariatric surgery, and requires us as the primary care provider to fill out what diets a patient has used in the past, their entire weight gain and weight loss history, and then “certify” that we think this surgery is medically necessary for them, and that they are “medically cleared” to undergo it.
Interestingly, we often receive this form immediately before the surgery, when we have not been engaged in the process all along the way.
Wouldn’t it be better, when the original decision was being made to evaluate a patient for bariatric surgery, if all those with a vested interest and medically necessary parties were notified, and kept informed of all of the things that were going on as the process progressed?
None of the bariatric surgeons should be surprised that they need this form completed, but they tend to not involve us until the last minute.
Fill this form out, or the patient’s surgery will be canceled.
Implied in this is that it will be our fault that the patient’s surgery is canceled or delayed.
When this works well is when someone reaches out to us early enough in the process and says this is what needs to happen over the next couple of months, this is what you care for the patient for, and this is what we care for the patient for, how can we work together, how can we optimize the patient’s travels through this healthcare journey they are on.
I’ve written before about how some of my favorite surgeons request preoperative evaluations from me.
They will read my office note, see the patient in consultation, copy their own note back to me, and then send me a message in the electronic medical record: “Fred, I think this patient should have X procedure, if that’s okay with you I’m going to proceed. Any recommendations?”
Together we’ve gotten dozens and dozens of patients safely through surgery without a lot of extra hoops that needed to be jumped through.
This is how we take care of patients, more efficiently, more collaboratively, and without a lot of clicking of boxes and excess busywork created by someone who doesn’t really understand what’s going on, chores that never really benefit anybody, either the patients, or the rest of the team trying to take care of them.
Interestingly, there’s a model for how to do this in the electronic medical record.
Although I’m not an obstetrician, I’ve learned that the EMR is designed so that it considers pregnancy as a single event, which has a beginning, at the first visit, and an end, after delivery when the postnatal visits have been completed.
Everything along the way is attached to this event, with multiple participants who have clearly defined roles, and a standardized progression, a timeline with tasks, from beginning to end.
Wouldn’t it make sense for more things to work this way, for all of the care to be optimized in a collaborative way, so that we all knew what everyone else was doing, so that we all knew what we needed to do when we needed to do it?
What if, at the onset of the evaluation for bariatric surgery, everyone who ultimately needed to be involved was informed, and this timeline was created, assignments were made, expectations clarified, and no one was left in the dark?
I’m sure that every member of the team needed to get patients through bariatric surgery (from the surgeon doing the procedure to the nutritionist advising the patient to the sleep medicine doctor performing the sleep apnea study to the gastroenterologist doing the required scoping to the psychiatrist assessing the patient’s mental state) would all want to know and be involved, taken out of their silos.
And for the first patient I described above, what if all members of his team, including his home care nurses and the agency they work for and the durable medical equipment company and his insurer, all agreed on the fastest and safest ways to always get him everything he needs?
I envision a more efficient way of taking care of people where we all work together to move them from point A to point B.
With that key, we can open any door.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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