Why are we treating outpatients like inpatients?


Every action that is taken, especially when it comes to healthcare, has ripple effects, which often end up being more far more significant than we anticipate, turning that ripple into a tidal wave.

Every time somebody besides actual health care providers steps into the mix and tell those of us taking care of patients that there is “something else that we have to do,” we often see it open up a proverbial can of worms that in many cases we didn’t want opened.

Whenever government regulators, hospital administrators, the makers of electronic health records, or bureaucrats from insurance companies, come up with creative new things they’d like us to measure or insist that we do, this usually leads to an increase in the burdens on an already stressed-out and burned-out health care community. And it often happens in the vacuum of not asking us, the ones right there taking care of patients, whether this is really worth it, really the right thing to do.

Take for example the well-intentioned addition of pain as the fifth vital sign. This came about in an environment where many people felt that providers were inadequately addressing the patient’s pain, and not using the medications at their disposal (i.e., opiates) freely enough.

I remember our practice getting cited by government regulators making a site visit after reviewing a chart and finding a pain score of 8 listed for a patient, and at a follow-up appointment there was no documentation of why that number had not gone down.

There have been numerous well-written and thoughtful articles recognizing this simple change in the medical record as being a contributor to what we’ve since started to call the opioid crisis in this country.

We created a system where we’re jumping and responding to a click in the chart, a number on a scale, an endless stream of screening questions, performance measures, risk stratification categories, and guidelines.

I’ve written before how the implementation of an accountable care organization at our institution led to a brand-new set of screening questions that someone has decided we are being measured against.

Falls risk, depression screening, blood pressure under control, and being over- or underweight.

Just because someone has decided that these are useful measures to look at, do we really believe that it needs to be done for every patient, and in fact, does knowing the answer really always help us?

By putting this in place, we are essentially agreeing that there is significant evidence that asking this question, getting an answer, and then performing one of the available options is going to make a difference in the future appearance of that event, or avoidance of some future outcome of interest.

Take for instance the falls question built into the electronic health record. This is an automatic default question that pops up once someone is entered in the accountable care organization, and is not based on anything other than their enrollment in Medicare. There is no effort to actually assess whether any particular patient is at increased risk of falls.

In fact, our practice has many patients who are at extremely high risk of falling despite not being over age 65, yet this question is not “available” for them.

And I have many robust 80- and 90-year old patients who I doubt will ever fall down.

“Has the patient experienced a fall in the past six months?”

Once the patient screens positive for falls, there are limited options made available for the provider to click to say what they plan to do about this.

These include a promise to change their medications, suggesting that we’ve left them on a medicine that places them at increased risk for falling. Or referring them to physical therapy, assuming that this intervention will prevent future falls.

I’m not saying that these aren’t good things to try, we should all be striving to take medicines that put our patients at risk for falls away from them, and physical therapy could probably help everybody, especially our frail elderly Medicare patients who have fallen in the past year.

Once again, we’re being asked to click a bunch of boxes, the answers to which we don’t always have the right tools to make better, the right team assembled to attack the problems that we’ve uncovered.

When we ask any question or order any test on a patient, we should always be mindful that what comes out the other end is an answer, and we better be prepared to do something with whatever that answer may be.

I’m not saying we shouldn’t be asking, I’m just saying we better make sure we have a health care system in place that’s ready to do something about all the answers we get.

Look at the review of systems that is built into nearly every encounter between a health care provider and a patient.

This is a structured system of inquiry that has been put into place whereby the providers hopes to glean information about symptoms that may not have come up in the patient’s history, or may have come up but need to be further explored.

The shorthand way of asking about these things during, for instance, an annual physical, is the simple question, “So, is anything else bothering you?”

Sometimes this will get a patient to think about their lower back pain, or their problems with urination, or that rash they forgot to mention, but often times, the short question gives you the short answer, “No, everything else is doing okay.”

If you break the review of systems out further to the multiple organ systems, you increase your chance of getting more detail, but this comes at a cost of time, as well as more answers to questions that we now may need to pursue further testing and evaluations for.

Constitutional. HEENT. Respiratory. Cardiovascular. Gastrointestinal. Endocrine. Genitourinary. Musculoskeletal. Allergy/Immunology. Neurologic. Hematologic. Psychiatric. Skin.

You can scroll through these systems, working your way up and down the patient’s body with them, again sometimes uncovering new symptoms simply by presenting these large categories to them, but often people will just say “Nope, everything’s okay there.”

But if you really open up Pandora’s Box, and go through what is known as a “detailed review of systems,” the number of questions asked and potentially answered telescopes out very quickly.

For instance, in our electronic medical record, here is the list of review of systems under HEENT:

Congestion. Dental problem. Drooling. Ear discharge. Ear pain. Facial swelling. Hearing loss. Mouth sores. Nosebleeds. Postnasal drip. Rhinorrhea. Sinus pain. Sinus pressure. Sneezing. Sore throat. Tinnitus. Trouble swallowing. Voice change. Eye discharge. Eye itching. Eye pain. Eye redness. Photophobia. Visual disturbance.

I’m short of breath just reading the list, and we haven’t even gotten to the respiratory review of systems, let alone dealing with all those positive responses.

I recently wrote about a new project, looking to start remote patient monitoring, where certain high-risk patients will have a medical device placed in their home that allows for nearly continuous monitoring of their vital signs.

For the most part, I don’t want to measure these things unless there’s something that makes me think they’re going to be significantly out of range and that I can do something about it.

Suddenly, outpatient providers are responsible for huge load of data that was previously collected only on sick inpatients who had a team of nurses watching over them 24 hours a day.

To measure something, to ask a question and get an answer, will make providers feel like we need to be the ones owning responsibility for what that answer tells us.

As health care providers we need to be the ones deciding what gets asked, and answered.

And we can’t do it all on our own.

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 MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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