One of the not often discussed challenges of our EHRs may be getting patients to the right medical resource at a time most suitable for their medical condition. Our electronic systems, whether automated by algorithm or assigned to a person given a protocol have become too separated from medical care itself. Our schedulers are no longer ourselves or our secretaries trained in the variability of patient needs, which can then be reflected in physician encounters. Sometimes the condition plays out over months, requiring assessment over an interval dictated by the condition. Some diseases really shouldn’t wait for assessment for the next computerized opening three months distant, either because the condition is self-limited, leaving the provider nothing meaningful to assess, or because some anticipated but avoidable deterioration occurs before the next opening. We have screens, slots, provider names, either open or blocked out or already filled.
As I transition from a retired physician to a seventy-something with long-since expired parts warranties, this has become more apparent, though noticed in my working years as we transferred from wire-bound soft-covered annual scheduling books annually in a different color from a medical stationer to a perpetual electronic module where somebody sitting remotely from either doctor or caller matches where people can be typed onto the screen, often to the disregard of medical need. These systems do not seem to account for what happens to people with different conditions over set intervals, resulting in avoidable suffering for some, defaulting to providers who are available but really not as experienced in assessing a particular condition as somebody else with a schedule already saturated with patients that the less experienced physician could have handled, or in the other direction, premature appointments at intervals too short for the condition to move to its next phase. I miss that appointment book with its faux leather cover in the custody of an experienced part of the office team who knows what needs attention quickly and with authority to inconvenience the doctor, also part of that on-site team, based on experience and mutual professional trust.
Recently I felt a sudden tear followed by a pop with a grade eight very sad face on my fifth vital sign. Something tore above my right greater trochanter. ER, urgent care? After a discussion with the on-call primary doctor, by then able to bear weight, we concluded that what I needed was an exam by somebody who knew what pelvic and thigh muscles attached to what. On Monday, I called the orthopedic office. A remote secretary from a call center offered me an appointment a month later, by which time I would be recovered or disabled. Having opted out of an ER visit on Sunday disqualified me from any need for their doctor’s promptness. So exam by the primary doctor, advice on symptoms, and see what a few weeks of the null hypothesis does to the natural process of suspected tendon rupture. Or perhaps recovery with the cancellation of appointment in favor of somebody who might benefit more.
In a similar vein, from diagnosis of iron deficiency to examination of its source took seven months, with a little iron sulfate and some CBCs to see if maybe a different endoscopist in the group should do it in a more timely way than the doc who did my age-related screening, though contrary to group scheduling rules. The great irony came a week later. Call from the office; I must come in next week to discuss this. What they found evolves slowly over the years to decades, and I have been on the usual treatment for years. What is the urgency of appointment? Her vacation and endoscopy assignments would delay the office visit by six weeks if not done in two days. I opted to wish her a good vacation and come in person at a less pressured break in her endoscopy assignments.
For primary care, another pseudo-urgent scheduling need. My wellness assessment was nearing its one-year repeat eligibility, so I needed to make an appointment for three months. However, I also get medical care for the things she prescribes medicine. Those are properly assessed at six-month intervals, with a visit overdue now. But protest from the desk, they cannot do their wellness. I still need my semi-annual medical care now, not the wellness visit. That can wait another six months with the next anticipated medical care visit or done independently when OK with Medicare. But right now, I was already three months overdue for reconsideration of my medicines and related lab work. They reluctantly agreed. Some things are better done now, others better postponed. Which is which depends on the medical situation, not on what open spots the computerized scheduling flags for the remote clerk to insert a patient name. Alas, being taught to think situations through, the essence of medical school and much of medical care before the computer dominance, has been devalued. There is some harm to this.
In practice, I would see hospital consults for hyperparathyroidism or elevated TSH or diabetes in various stages of evolution. Everybody reappeared on my office schedule within two weeks. The asymptomatic calcium will not change in that interval, the response to the levothyroxine started or adjusted in the hospital will still be in transition when they appear in the office, and the end organ situation of their diabetes was addressed in the consultation. Had that same diabetic been evaluated in my office, the next visit would be two months, not two weeks, and scheduled by my own front desk on my instruction with me personally two doors away if any special consideration was needed. As these already resolved hospital consults fill up the slots, transmitted from a remote central site by somebody who cannot challenge what she is told to do, then link to my office scheduling module, that same number of people referred by their physicians calling that call center are told that I can see them in two months with no distinction between chronic failure to meet lab targets or symptomatic hyperthyroidism right now. Offices of my frequent referrers know who to call to correct the unreasonable. The City Health Center or other clinic sites for the uninsured tend to accept the reality of central scheduling, the same as their network with their computer system utilizes.
We have a lot of patients who benefit from our care. Centralizing scheduling to a few employees dedicated to the task generates efficiency. But with that specialization should also come expertise. An element of triage has never been built into those formats, something our individual offices with a front desk authorized to exercise good judgment once did. One more part of our EHRs to fix.
Richard Plotzker is an endocrinologist who blogs at Consult Maven.