Patient Portal Success

“Doctor Nieder, my wife got this new smartphone and she wants to know why she can’t communicate with you using it. Can she?” This coming from a 70 something patient. I’d seen his wife a few days previously and she had a question about her medication. She wanted to know why she couldn’t just email me about it.

We talked a little bit about the insecurity of email and personal health information (PHI in my world). Then I happily explained that,  indeed she could communicate directly with me using her smartphone. I gave him my card with the RelayHealth information on it, directed him to look to the upper right-hand corner of the website and click “register”. This will take her to this page:

Relay Health Sign in

 

After finishing the registration process, pick a provider – me – and then RelayHealth sends me notification of the registration. After that she can directly communicate with me. He left the office happy to have good news for his wife.

I know many of my colleagues are hesitant to give patients direct access but consistently the portal has saved me more time than cost me. Patients ask thoughtful appropriate questions. If an appointment is needed a staff member calls them. Otherwise I can give an equally thoughtful response on my own time. As they say “It’s a win-win.”

 

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Is Happiness a Value?

Glancing at my blogroll tonight I came across a recent post by Kent Bottles entitled, “How to Practice Medicine in a World We Can Never Truly Understand“. While it is a little esoteric for this family doc’s brain, reading it jogged my thought processes. He begins by discussing the pursuit of happiness, an ofttimes elusive goal in life. Is it unusual that happiness was never something for which I aimed? The closest value for me was satisfaction. As my children grew, I encouraged them to give the best they could in life–whether that was grades or friends or sports or art. Never once did I suggest they try to be happy. For me, happiness is something one may find, but when you make it a value, now there’s a recipe for disaster.

My patients will tell me “I just want to be happy”. They believe they will achieve that goal if they marry the right man, find the right job, get the right grades or buy the right ______ (insert necessary object here–car, house, dress, purse). Doing the best job in the job they are in, making the best grade in the most challenging class they feel competent to take, being the best friend to the friends they have…these are not enough. If they are not happy in their job or class or relationship, it is of little value, unless it can be justified as bringing happiness in the future. They search in chemicals to achieve happiness, be that legal (Prozac, Paxil, Adderal, etc) or illegal. If they are not happy, then something must be terribly wrong, even if they are unhappy for legitimate reasons; their mother just died, they lost their job, their boyfriend broke up with them. Their friends encourage them to take medications to be happy again.

This can be a type of cultural divide in an exam room. In the same way that language barriers can reduce good care, value differences make for dissatisfied patients who may intellectually understand that exercise will improve their health but if it doesn’t make them happy to do it, it may not get done.

Happiness has followed me in my life many times. Most would consider me blessed. I wasn’t looking for it. It’s nice to have. But at the end of the day, I don’t want to be happy, what I want is to believe that today’s accomplishments were the best that could be done under whatever circumstances I found myself.

In other words, satisfaction without regrets. Happiness may follow.

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Dying With Dignity

She is always put together perfectly and today is no exception.

She’s tells me how she’s giving away her things and I decide against complimenting the beautiful opal she wears, fearful she might hand it over. We’ve been together for six years yet I know so little about her. Her husband is also my patient and has been very ill for several years. Despite his many medical issues he seemed to take care of her so it concerned me that he would die first.

Death decided he wants her instead. He stalks her but she stays gracious, not giving in to despair. She asks me about my daughters, she is honestly curious. She talks about how much her energy has ebbed but she is no longer frustrated by it. She teases her husband a little.

As she leaves she thanks me for taking such good care of her. How can she say that? I’ve failed. Neither I nor the oncologist can stop this inexorable process that is whittling her down to nothing. She hugs me as she leaves and I feel healed. What a startling reversal of roles.

 

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Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger’s Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of “careless care” appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a “sinus” infection, despite the fact that each time she’d only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.


We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she’d not come in sooner with the previous episodes.


The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger “Little Clinics” where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 


As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can’t fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients’ physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.


1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305http://www.webcitation.org/6F5uFLPIY

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Are Doctors the Ultimate Engaged Patients?

My nose and sinuses feel like they are about to explode. I am moving into the third week of this and it’s getting old. At first I thought that my cold had morphed into allergies but now it is apparent that two viral loads in a row have slammed me, both affecting my upper respiratory tract. If a patient walked into my office as miserable as I am right now my advice would include a steroid dose pack to shrink the swelling, some decongestants, lots of fluid and rest. Since it has been going on for so long if the patient insisted I would probably toss an antibiotic in there as well though it is clear (to me) this is not a bacterial infection. I am using a multi-symptom nighttime OTC cocktail along with a topical antihistamine at night and a decongestant with a expectorant during the day. I have no fever and there is nothing to suggest a bacterial component.

Reflecting on my illness, it occurs to me that one of the reasons doctors are uncomfortable taking care of doctors is that we are the ultimate e-patient. We are participatory, we understand the underlying disease processes and we often waver between allowing the treating doctor to be in charge and taking charge. We want to be partners in our healthcare because we have the training for it and yet hesitate because that’s not the way it’s done. It brings to mind a moment in my first pregnancy (in eastern KY) when my nurse midwife told me to skip the hospital prenatal courses because I needed to be a patient, not a doctor, and the classes would thrust me into a difficult role in such a small community. I remember feeling relief and feeling good about “only” being a patient. 

Those times when I have needed to be a patient my choices in physicians have assured me that I would be a partner in my healthcare decisions. Most doctors find taking care of other doctors, or their family members, challenging. This can be both self-inflicted and patient-generated. As patients become more engaged in their healthcare perhaps taking care of our own kind will become less anxiety-producing. We will feel confident that no one is “only a patient” because all patients will be partners if they so choose. 

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Gluten

My daughter is a barista. She came home from work recently and said, “One of the customers came in today and wanted to know if our hot tea was ‘gluten-free’. Seriously? It was all I could do to keep from asking her if she knew what tea was made of!”

Gluten sensitivity is a hot topic these days as illustrated by a recent article in the New York Times “Gluten Free-whether you need it or not“. I have many patients who are curious about gluten-free diets.  Patients are trying them and losing weight, having fewer migraines, reducing PMS symptoms, getting more energy, and/or making allergies going away. After having been in medicine for a sufficient number of years the exuberance of interest in gluten reminds me of any number of healthcare fads. Because we are human we hope to find an easy answer to our lifestyle problems. 

When patients ask me what I think, my answer is usual a very definitive “I have no idea.” Then I elaborate since that tends to be disconcerting to them. First I need to know exactly why they are asking. Do they have symptoms of celiac disease: constipation, diarrhea, nausea, weight loss and abdominal pain (which can be caused by any number of entities besides celiac sprue)? Have they read something on the Internet or heard from a friend about gluten sensitivity and believe they have a problem? Are they presently following a gluten-free diet and if so, for how long and how do they feel? Only after I know where my patient is coming from can I decide where I need to go with her in the context of the visit.

For most individuals I want to be reassured that they are eating a nutritionally balanced diet and beyond that, I don’t have easy answers. Usually I find questions like this involve a bit of fact, some fad and most definitely the hope that this “latest thing” will solve their problem, whatever that problem may be. In terms of my response, most things in medicine, like life, are best answered sensibly: All things in moderation.

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Saying Goodbye

It’s Friday afternoon and I check the day’s schedule. A name jumps out at me and I groan a little and worry–what am I going to say to someone I’ve treated for twenty years, who’s my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn’t have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering “I love you” in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It’s probably obvious that I’m upset but the rhythm of seeing patients takes over and somehow, reassures me.

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Cynical Thoughts about Medical Insurance

Is anyone else irritated by medical insurance companies’ efforts to improve the health of their members by encouraging them to do recommended tests based on claims-made data? Recently, a patient asked me if he should get the pulmonary function tests his insurance company recommended based on his asthma diagnosis. He does have mild intermittent asthma. He uses a steroid inhaler once a year during the spring for about a month and might use his rescue inhaler with exercise four or five other times during the year. If you check the guidelines put out by the National Asthma Education and Prevention Program it is recommended that a spirometry test or PFTs be performed annually to assess any changes in lung function. The fact is, this patient has been treating his asthma the same way for about fifteen years. He feels fine. So will doing PFTs make a difference? We discussed it (over Christmas and through the patient portal, which I love) and decided that doing testing was unlikely to cause a change in therapy. Since he had better things to do than PFTs he would prefer to skip the tests. Hopefully he won’t see an increase in his premium for refusing to follow his insurance company’s medical advice. Does this make me worry about becoming nothing more than a flunky ordering tests for patients based on Humana or Aetna or Anthem’s “best practices”? In a word, yes.

What irritates me more, is being faxed long lists of patient names with recommendations for mammograms, colonoscopies or diabetic eye exams. Our office is supposed to pull those charts and encourage patients to have their preventive exams. Of course if we do pull them, it turns out the “claims-made” data from the insurance company isn’t all that accurate and many patients have already had their tests done. Thus another waste of the office employees’ time pulling charts. Hopefully it will be easier with electronic records.


I suppose the cynic in me wonders “What’s the angle here?”. Does the the upper management of these companies really care about the members they insure that much? Is that what it takes to continue to make the obscene salaries their positions pay (see chart below)? When Humana sends me yet another envelope full of “healthy” coupons in their quarterly newsletter that shows me how much money they saved me with my last doctor visit, complete with lots of “healthy advice” enclosed, why does it make me roll my eyes?

When I want medical advice I will talk to my doctor or find an expert on-line, I will not talk to my insurance company. I do not want or need coupons from Humana. Nor do I want my insurance company to remind me of preventive care visits via my telephone. My patients are thrilled by it, however. “Humana pays for me to go to Silver Sneakers! Isn’t that great?” or “A free 30-day Jenny Craig membership is available, what do you think doc?” 

Just call me Thomas, because I am a doubter. Nothing is truly free in the insurance business, so somewhere along the line the consumer is paying for the SilverSneaker membership and the salary of the individual who is soliciting companies to provide coupons from the insurance company. Please, just pay my claims and not give me such a headache trying to obtain my prescription from your 90 day pharmacy service. That’s what I would call good service! 

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Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

  • Physicians lack the time to call colleagues about patients when their income is patient volume-based 
  • Fewer opportunities for direct physician contact, i.e. the doctor’s lounge
  • EHR systems cannot talk to each other
  • Patients don’t always tell their physicians about other doctors taking care of them
  • Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
  • Patients rarely carry their health histories with them in any format outside of memory
Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of “junk”, making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues–problems with EHR, announcements, medical directors’ updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that “If you build it they will come” does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I’m a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I’m reading Sharepoint for Dummies, I can’t help but wonder–what was I thinking and can this make a difference? 

References:
1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf
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