Now I think I'm just getting mad.
Through the years, this column has been a place where I've been able to point out problems and challenges in the healthcare system, and hopefully not just complain but make some helpful suggestions, grounded in common sense and experience. But it seems that we've just not been able to move the dial. There are more meetings, more guidelines, more bureaucracy, more clicking in the electronic health record, and providers and patients seem more frustrated, fed up, and tired of not getting what we need out of the healthcare system we have.
A Failure to Refer
Here's an example. About 2 weeks ago, a patient called up our practice requesting a referral for follow up of a routine issue with a specialist. Due to what looks like an error in how the message was routed in our system, as well as someone being logged into a messaging pool they shouldn't have been (and didn't know they were logged into), the message was marked as "done", and fell off of everybody's radar.
Time went by, no referral was sent to the specialist's office, and on the day the patient showed up they were told they could not be seen because their primary care doctor had failed to put in a referral and have it processed with their insurance in advance of their visit. This led to some further phone calls to our practice, some further back and forth inside and outside of the electronic medical record, more miscommunication, and before we know it the patient had been turned away from the other doctor's office. Ultimately someone was able to step in and save the day, and we called the patient on their cellphone and they were able to go back and be seen.
How many ways can this go wrong? Start from the fact that our patient getting seen in a specialist's office all hinged on the act of a referral being placed in the EHR, processed on an insurance company's website, and then faxed over to another office. That seems like a contorted process to try and help our patients get healthier. And within that system of messaging and responsibilities within the EHR, many problems ensue. We all get unexplained messages, results on tests we didn't order, messages on patients we've never met, and paperwork to sign on patients for whom we've never been involved in their care.
It's just such a clunky and inefficient and not very useful system that we've let become built up around the business of taking care of patients, and it feels like we need to tear everything down and start from scratch. If our patient is being seen by a specialist for the ongoing care of a problem that that doctor is managing, why do we need to be involved at all? Maybe we transfer the work of being sure that the patient has the referral they need back to the insurance company, who has an interest making sure the paperwork is in place so that the doctor gets paid for their services.
A Contorted Triage System
Take another example. Last week we were on a team conference call about the processes we've been building to transform our telephone triage, the system whereby the folks at the answering service, whenever they hear a "trigger word" such as swelling, headache, bleeding, or chest pain, immediately transfer a call over to a nurse for a clinical evaluation. This initially seemed to make a lot of sense, an opportunity for the nurse to triage the call and see if this was a chronic problem that could wait, or whether this patient needed to be brought into the practice more urgently for a same-day or next-day appointment, or whether they needed to be referred directly to the emergency room.
What we discovered was that once the nurse had decided that the patient should be seen today, instead of sending the patient back to the person who had sent them the call in the first place, they were supposed to try and reach out to a chain of people at our practice, ultimately one of whom was meant to answer the call, take down the information, and then forward this to our local schedulers who would then schedule the same-day appointment with our patient. Seems a lot more complicated than it needs to be.
I said to the people on the call, "Why don't we just have the nurse route the call back to the scheduler who sent them the patient in the first place, telling them when the patient should be seen -- that is, later today, sometime tomorrow, or as a routine follow-up in the primary care provider's next available appointment?" The system doesn't work that way, they told us -- the moment the scheduler passed the call on to the nurse, the "event" (the call) was technically "closed" in the scheduler's system, and there was no way to get back to the original person. This feels like we've created a system that's fraught with opportunities for error, duplication, and delays that interfere with getting our patients the timely care they need.
They said that this was the way the system has been built, and although they thought we had some interesting ideas, they didn't think it was likely that things would change.
Another example of this is the insistence on a pain score. Many years ago, heavy hitters in the healthcare industry decided that asking about a patient's pain score at every single office visit was the right thing to do, and the recording of pain in a patient's chart became a "hard stop" in the electronic health record -- something you couldn't bypass to carry on with the visit until it had been recorded. Many of us on the front lines thought this was overkill. Are you telling me that if I'm seeing a patient for hypertension on two consecutive visits, I have to put in a pain score on both, even if I'm not addressing their pain during either one?
Today, many years later, it's clear that this small thing, this recording of a number from 1 to 10, likely had a great deal to do with the worsening and entrenchment of the opioid crisis in this country. This obsession with pain and the incessant need to drive a number down seems to have done much more harm than good.
We Must Call for Change
I'm not saying we're always right about all the suggestions we have, all the ideas we have about trying to change things. There are many smart people out there in the spheres of the hospital administration, healthcare management, and EHR creation that have been and will continue to be an incredibly important part of the process of caring for patients, and they provide useful tools and insights that help us every day. But over and over again we keep saying that things aren't working, that our patients aren't getting better, our country is still spending trillions on healthcare with little return for the dollars we are laying out.
I know that we can't do it on our own, that we need the rest of this infrastructure supporting us. But the voices of those on the frontline caring for patients, in the community and in the office and in the hospital, need to be listened to. If we just keep paying lip service to these calls for changes, we're likely to continue to get the result for which this healthcare system is so perfectly designed -- this system with horrible inequities, poor access to care, poor outcomes for so many of our patients, and missed opportunities to prevent disease.
Yes, bringing about this change is going to be messy, and is going to have some growing pains and missteps. But if we don't acknowledge that so many things just aren't working, and don't listen to the voices calling for a better healthcare system, we're never going to be able to get there.
As we've seen during the pandemic, the system is stretched thin. We are not providing the best care we can, and our providers and our patients are suffering for it. So I only hope that we can join our voices together to raise up a clarion call, to make those with the power to bring about change and create a better place for patients and providers throughout the healthcare system listen to us. Or we are sure to find ourselves in a place, 5 or 10 years down the road, no better off than we are today, trying get people riled up with a call for change.
Tell me how mad you are, on a scale of 1 to 10.