Just the other day one of the medicine residents presented a case to me, and mentioned that in looking through the patient’s chart he noticed that the patient had undergone a prostate biopsy 1 month prior to this visit, with a follow-up appointment in urology scheduled next month. The result of the biopsy was positive for cancer, but that had not been communicated to the patient. His first instinct, he said, was not to tell the patient, but “just let the urologist do it.”
He said he was addressing a number of other medical issues that day, and did not know that he was going to have to be giving the patient such bad news. He and I discussed several points about this, including the fact that this was his patient, and that he should be giving the patient the best information possible.
What if the patient was secretly wondering if his biopsy was back, and that his doctor must have seen the results, and maybe since he wasn’t saying anything that day it meant good news, and therefore he didn’t need to see the urologist for that follow-up appointment next month?
I have seen several of these “devil’s advocate” situations play out, and sometimes patients don’t show for the follow-up appointment and the results are lost forever in the ether.
How did this situation even arise? How in the modern world of health care today, with all our electronic health record bells and whistles, has someone not communicated these results to the patient 1 month after the pathology report comes back with a serious finding?
Who “owns” this result, who owns this patient, who needs to do the telling?
Much of this responsibility seems to default to us as the primary care providers, but we also need to focus on building a better system, so all our patients will never miss an abnormality that needs follow up.
Our electronic health record contains powerful tools that allow patients to automatically receive their results via secure email. Lab results are released to patients within 48 hours, and radiology and pathology reports are released at 96 hours. Once the patient enrolls.
Having a system of automatic results release has already dramatically decreased the number of phone calls to our practice, allowing us to quickly communicate both normal (and at times even abnormal) results to our patients.
But getting buy in from patients on the use of a patient portal has been variable at best; often they fear having their records travel over the Internet. Even after we tell them that the secure system run by the hospital has apparently never been breached, many patients are hesitant to sign up. And with the recent revelation that the NSA is reading all of our emails, texts, and Facebook postings, I tell them that if someone wanted to know their cholesterol, they probably already do.
Most of our patients have access to email, and the patient portal is even available on smartphones. To be able to reach all of your providers, communicate about all of your health conditions and concerns, is an extremely powerful thing for our patients to have, and a critical component of the patient-centered medical home.
Patients are able to review their records, update their medications, review their health care maintenance to see missing interventions. They can ask questions of the practice (although there are large warnings telling them not to leave messages about urgent health matters like chest pain). In the future, patients will be able to request appointments, and even insert themselves directly into open slots on provider’s schedules.
With the click of a button, the patient can request a refill of all of their medications, and with a click of a button I can reply and e-prescribe to their pharmacy, saving at least five phone calls, and over a half an hour.
Getting back to our patient with the abnormal biopsy results, I have long been a proponent of a closed loop model, where 100% of results are followed up through built in systems. How can we biopsy a prostate or breast lesion, and not know that a plan for follow-up and giving the patient the news, good or bad, is in place?
Putting aside the issues of professionalism and responsibility, in the patient-centered medical home we need to build a system where we stand as advocates at our patient’s side and give them all the tools they need to achieve optimum health.
Using the members and the structures of the patient-centered medical home, we are building a more efficient and confident system of communicating results with patients.
I can’t tell you how many times I’ve asked patients about the results of tests ordered by an outside provider only to hear the much-dreaded answer “well, I guess no news is good news. If something had been bad, someone would’ve called, wouldn’t they?”
Recipe for disaster.
Of course there are myriad problems of language discordance, low health literacy, and socioeconomic challenges that may prevent patients from gaining access to all of these electronic systems and their benefits, but we are actively working on solutions to these as well.
Meanwhile, it’s absolutely critical that we close the loop — patients must be given the results of their tests, and as their primary care physicians, we may well have to be the ones to do it.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.