Let the Patient Write The Referral Letter

On the portal this morning I received a great note from a patient. He’d seen two specialists and was checking in to tell me what had happened in those visits. His summaries were succinct, tell me exactly what I needed to know about what transpired. It took me about a minute to read them. Since the advent of EHR-generated referral letters I’m unsure that I’ve read a better referral note.

After reading it, I knew the assessment of the problem, the treatment plan and when he would be seeing them back. I did NOT receive one to tenMedical_Software_Logo,_by_Harry_Gouvas pages of past medical and family history that I already knew. I did NOT receive a list of the medications he walked in the door on, which I already know. I did NOT receive his insurance information, which I already have. Etcetera.

When will EHR vendors be able to extract information and template a referral note that only contains what I need and not streams of unnecessary information that gets in the way of my being able to read what I do need to know? When will physicians help the IT department cut out all the useless crap in those letters? If they’d like the name of my patient to help them, please contact me. I’m sure we can work something out.

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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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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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Physician Patient Communication

All professions need good communication skills. Obviously in healthcare the ability to communicate with patients should rank high in a physician’s list of talents. These days that interaction occurs in a number of ways: face-to-face, direct telephone contact or though a staff member, via emails, patient portals, or even texting. Because the communication is in the arena of medicine, the protection of an individual’s health information is paramount. Enter HIPAA, which is a federally mandated program to ensure patient confidentiality.

The face-to-face form of interaction is the most rewarding because multiple senses are used in the process. First, I listen to the words while hearing the tenor of a patient’s voice; a few octaves higher with anger or fear, deep and gnarly from years of smoking, “push” of speech in an anxious or grandiose individual, or an accent that might be heavy enough for me to wonder if there is a cultural or comprehension problem. Sight gives me other cues; body language–crossed arms, angry face, tearful, an open posture, a resigned facial expression, stiff limbs or back. Sometimes my sight reveals more concrete things–bizarre tattoos, picked at sores, expensive accessories, worn and torn clothing. My nose may be assailed by the scent of the smoker, too much perfume, not enough soap, musty clothing or pleasant shampoo–all of that speaks to me. Finally touch–dry and peeling skin, a mass somewhere it shouldn’t be whose texture may speak to me of reassurance or of terror.

The opposite must be true as well. We speak volumes to our patients without opening our mouths, or despite opening them. The tenor of our voices may be patronizing, authoritative or uncertain. Our faces and body language reveal our thoughts with a roll of the eye, crossed arms, or open facies. We can look professional or casual. Smell can be important–what asthmatic wants to see a physician whose aftershave or perfume is overwhelming? Perhaps touch is the most expressive. Early on I learned that even when I don’t need to, patients expect to have a “laying on of hands” in some fashion. They may trust you less if you haven’t at least looked in an ear or listened to a heart.

The hardest communication for me is remembering to finish with eye contact and a plan: “We’ll contact you with the lab results”, “I will have our referral clerk Megan call you” or just “Have a great holiday” instead of rushing out to see the next patient. But the best visits include a hand shake or on a good day, a hug.

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Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor’s lounge.


Despite Meaningful Use criteria breathing down our organizations’s neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He’d had surgery shortly after but he wasn’t sure whether or not he’d had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he’d had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn’t convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I’d just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he’d first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: 
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Communicating via Patient Portal

It’s Saturday night and I’m tying up loose ends, signing off patient referral letters, sending messages to staff to do on Monday and “playing” in the test environment of our EHR to try to better understand it. My husband is working a 12-hour shift at an immediate care clinic, my daughter is with a friend and the cats are not trying to get in my lap right at this moment. The house is quiet, with nothing but the soft swishing noise the dishwasher makes and for some reason, that always soothes me. Maybe because cleaning is happening without my active participation. It occurs to me that I haven’t checked RelayHealth.com, our patient portal, since early yesterday morning. 

RelayHealth.com

I log on and there are two messages. One from a patient that needs her atorvastatin refilled. I thought it had been done at the time of our visit yesterday but when she arrived at the pharmacy only her blood pressure pills were there. Apparently I neglected to check the drop down box in the prescription area of our EHR. In her case the default setting was “record” instead of “send to retail pharmacy” (it varies per patient for some mysterious reason) and I missed checking ONE of the three prescriptions correctly. This is a system problem that needs to be addressed but in the meantime my patients will sometimes get less than all of the multiple prescriptions they need refilled. The good news is that she figured out how to use the portal, sent me a message, I read it and immediately logged back into the EHR system and sent the prescription to the pharmacy. Then I messaged her back to say the prescription should be ready in the morning. COOL!

The second message is from a patient who has found data regarding the use of metformen and psychiatric disease. She is tech savvy and figured out how to scan and send me a PDF file of the published research. COOL! Now I’m learning from my patients even when I’m not in the office. I send her a message promising to read the article and get back to her and jokingly tell her that I hope all my patients aren’t as smart as she is or I’ll be inundated with reading material. Tomorrow I can respond to the article.

So far not a large number of my patients know about or have bothered to sign up for the portal but I’ve been very happy with the interactions I’ve had on it. Earlier in the year a woman had an illness that seemed to linger forever. I was running tests and talking to specialists and was certain that this would pass but it was frustrating for her. I think it helped both of us that she could communicate directly with me throughout the illness and may have saved her some trips to the ER or Immediate Care Center because she had direct contact with me on a nearly daily basis. In return it was a relief to me to know how she was doing.

Physicians often hesitate to give this kind of access to patients because they are afraid it will be abused but that is short-sighted. Just like with the telephone, I have complete control over whether I answer or my medical assistant does. This way it can be done at my convenience and, in general, I hate communicating by telephone. Most patient messages are quick and to the point. If they need to be seen, I tell them so. It’s a plus to patient care from my perspective and am pleased with the results. I hope my patients feel the same way. 

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Post-its and the Practice of Medicine

Ever since the first Post-its® appeared in the early 80’s I’ve used the little colored sheets to remind myself about all kinds of things–telephone numbers, todo lists, shopping lists, dates to remember, notes for other people-especially my husband. I do not know how my mother, with her organizational genius, managed to survive without them.

When I began using a superb productivity program called Omnifocus, I thought my Sticky Note® penchant would be reduced. However, with the advent of EHR, I find it has done anything but. They clutter my desktop (my REAL desktop, not the one on my Mac) with quickly scribbled suggestions for changes requested or features not found on Allscripts (our EHR), thoughts for the blog, thoughts for future Vlogs, need for specific patient information, a book or website suggestion from a patient or my grocery list as I dream up an idea for supper tonight.

Later in the day I will quickly go through the stickies and move them to my calendar, Omnifocus, or if possible I’ll “just do it” (using a time-management technique by GTD® guru David Allen). They are ubiquitous in my exam rooms for writing quick info down with patients–a web site, recommended reading, an address, or medical term most often. Almost as frequently, they remind me to do something for a patient that would take too long to enter into the Electronic Health Record (EHR) or more commonly, it’s unclear where to put it in the EHR–like getting old records out of storage, obtaining recent ER notes, or looking up some particular disease state to research for the patient.

It’s clear that most other forms of paper will be disappearing from my office. Already the huge stacks of charts are disappearing, replaced with tasks or scanned documents in the EHR. Slowly, I’m beginning to appreciate the uncluttered appearance of my desk. However, I’ve found that its glass top, something I never used to see, makes a great surface for sticky note adhesive. 

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Mission Accomplished

Mrs. Smith is adamant, “That amlodipine is making me tired! I can’t take it.” Ms. Smith is 86 years old and her blood pressure is reaching a systolic of 200. She’s still mentally alert and volunteers at a local hospital every week, drives herself to places nearby and lives alone. It is scaring me because I don’t want her to stroke. This is the third BP med she has rejected in as many months. I’ve checked for other causes but think her age is just catching up to her.  Previously she has had a systolic in the 150’s and several years ago we tried several meds, all of which she refused to take. I gave up then but now I’m much more concerned. She has no family to speak of…we go over the pros and cons of the medication. She reluctantly agrees that if she dies from a stroke that would be fine but being in a nursing home unable to talk or walk would be horrible. She will try the medication for another month. “But doctor if I can’t do the things I want to do, I am not going to keep taking it!” She agrees to try it and surprises me with a hug as she walks out the door. “It’s OK Dr. Nieder, I’m not going to live forever.”

Tim Jones slammed his finger in a door and sees the hand doctor on Monday for a non-displaced fracture of his little finger. He wants to ride this weekend in a 100 mile bike ride for some charity or other. “Honestly, what is the risk?” We discuss the fact that the ride itself could cause swelling of the fingers and lots of pain, not to mention if he falls and hits it. “They splinted it really well at the immediate care center. I promise not to take too much ibuprofen.” I give my blessing and hope he is safe.

Mary White arrives, late as usual. My staff is used to that, so they try to schedule her at the end of the day. She has a short litany of minor issues, brings me up to speed on her minor medical problems with specialists, has her yearly exam, we discuss her perfect blood chemistries and she is out the door. 

After 25 years, my patients have me well-trained. And vice-versa–they only call me at night with true emergencies and they apologize when they wake me, they rarely call for last minute refills because they forgot, they bring their meds with them when they come for an appointment and they arrive on time because I’m on time (well, at least I was until Electronic Health Records began three weeks ago). Reflecting on my practice it occurs to me that this is what I hoped my patient relationships would be like at this point in my professional life. 

Mission accomplished. Wonder what comes next?

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I Thought I Just Explained That…

Helping patients to understand the effects of lifestyle on risk-factors, explaining lab results and discussing disease processes, that’s all part of my job, right? Patients go through their lists and we discuss strategies for improving their health. When they have a disease process we discuss alternative therapies, causes and second opinions. I use a white board which the patients seem to like, for writing down important points or drawing anatomy or sometimes just suggesting a book I think they’ll like. I love the idea of participatory medicine and have “taken the pledge” to make this a priority in my practice. I’m blogging and tweeting and watching other blogs. I think I’m pretty good at making sure the patient understands his or her medication, disease, and followup before they walk out the door. Then a patient comes in and knocks me for a loop.

After a long discussion with a young woman regarding what I thought was an allergic reaction she walked back to the waiting room where my office staff overheard her say to her mother, “Dr. Nieder has no idea what this is and doesn’t know what to do for it?” WHAT?!?!???!?!?!? Honestly I spent a long time discussing what I thought had caused her reaction and how to treat it over the next couple of days. It was not severe enough for a prescription so did she think that without a medication she wasn’t “really” being treated? Was the fact that her presentation was puzzling and I was unsure to start make her think that I never put the puzzle pieces in place? Thank goodness her mom asked to speak with me!

Makes me wonder how many times I think I’ve been communicating just fine, when in reality what I’m saying sounds like all the adults in the Peanuts videos.

Sigh.

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