Here’s Why You Should Ask Your Doctor To Show You Any “Alerts” In Your Electronic Medical Record

Electronic medical records (EMRs) make a lot of sense.  Ideally they capture, store, and report on all the pertinent information that’s floating around out there concerning your health.   One of the supposed advantages of EMRs is their ability to sort through vast quantities of health data to “alert” physicians to important gaps in your care.

Alerts are triggered when something in your EMR is flagged (think red flag) indicating that something that is supposed to happen to you has not yet happened….and vice versa    For example, EMRs can alert physicians when you are overdue for a screening test.  They can also alert physicians to lab and radiology test results that need to be followed up on.

It Is A Great Way To Engage Patients

Since everyone is so concerned about getting patients more engaged in their health care…why not start by turning the computer screen around and showing patients the “alerts” in their EMR.   I am sure that will get most patients’ attention.

Here’s why this is necessary

A study in a recent issue of the Journal of General Internal Medicine found that care gaps persisted among primary care physicians using EMRs and alerts.   Researchers found that:

• Physicians failed to follow-up abnormal lab test results in a timely fashion (<30 days) in 7% to 62% of patients
• Physicians failed to follow-up abnormal radiology test results in a timely fashion in 1% to 36% of patients.

Remember these where practices in which the EMR system was capable of generating electronic alerts telling the treating physicians that action was needed.  These follow-up rates are not all that different from similar studies of physician practices without EMRs.

The lack of timely follow-up by physicians reported in these studies resulted in otherwise preventable hospitalizations and delays in initiating time-sensitive cancer diagnosis and treatment.

In my wife’s case, her Non Small Cell Lung Cancer was identified in a hospital employee health screening when it was Stage 1… yet she was not told of the finding for some 5 years later at which time she was Stage 4.  This despite a “paper copy” of the radiologist report (chest X-ray) being sent to her PCP, OB-GYN and Employee Health Medical Director.

Why The Lack Of Timely Follow-Up?  

Researchers have found that primary care physicians in integrated delivery systems receive an average of 57 alerts per day.  Among the reason given for the lack of timely follow-up, despite the alerts, were the following:

•  Physicians were found to be less likely to acknowledge alerts when they are behind schedule.
• Physicians focused their attention on alerts concerning patients with greater “clinical burdens” (e.g., providers were more likely to acknowledge alerts about elderly or highly co morbid patients).
• Physician lack of knowledge – physician knowledge of EMR alert-management features in one study ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two.  Put another way, many physicians don’t know how to use all the features of their EMR system.
• Physicians ignored or turned the alert function off

The Take Away?

If you are a patient in a practice that uses an EMR, politely tell your physician that you would like to see any alerts that pertain to you.  If there aren’t any – fine.  If there are, simply ask your doctor what’s the plan for addressing the outstanding issue.  He or she may well have a good reason for ignoring the alert which I am sure they would be happy to explain to you.

If you are a patient in a “pencil and paper” practice, ask your physician what his/her policy is regarding test result notification, including timeliness.  Ask what their policies and procedures are to make sure that no one – particularly you – falls through the cracks.  Never leave your doctor’s office without a copy of all your test results!

If you are a physician with an EMR system…learn how to use the darn thing. Your patients will appreciate you for it and I dare say you prevent what happened to my wife and me.

That’s what I think.  What’s Your Opinion?

Sources:

Hysong, S.  et al.  Provider management strategies of abnormal test result alerts: a cognitive task analysis.  Journal American Medical Informatics  Association. 2010;17:71–77.

Singh, H. et al.  Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting.  Archives of Internal Medicine. 2009;169(17):1578-1586

Sittig, D. et al. Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert.  Journal of General Internal Medicine. 2012 Oct;27(10):1235-7.

Buy the Practice, Employ the Doctor & Pray The Doctor Has Good Patient Communications Skills

Hospitals today are aggressively buying physician practices in their local markets. Why? Hospitals want to solidify their referral base for inpatient and outpatient referrals as well as increase their negotiating power with insurance companies.

Over 50% of physician practices are now owned by hospitals according to the Medical Group Management Association. As such, many one-time private practitioners are now hospital employees.

Having done physician recruitment in a prior life, I know that before buying a practice hospitals look at a variety of things including the practice’s patient volume; number of hospital referrals, estimates of patient turnover and so on. One of the things we did not consider years ago in evaluating and buying a physician practice was the quality of the physician’s patient communication skills and supporting practices. I doubt that things have changed much since.

Hospitals today are under a lot of pressure from Medicare to address inpatient medical errors that compromise patient safety and often result in costly re-hospitalizations. As the line between doctor and hospital becomes blurred clinically and legally, hospitals need to start paying close attention to the way their doctor-employees communicates or doesn’t communicate with patients.

Consider the Problem of Medication Errors

Miscommunication between doctor and patient is thought to be a leading cause of such medication-related errors as patients not knowing:

• The names of all the prescribed medications they are taking
• Indications for using or not using the medications
• Dosage and frequency instructions

According the Institute of Medicine, approximately 500,000 drug errors or adverse drug events are reported every year in doctor’s offices and other outpatient settings.

In fact the evidence suggests that medication-related errors in ambulatory care settings may be substantially under reported. Consider a recent study of patients prescribed a blood thinner – Warfarin. Among older patients, Warfarin, and similar oral blood thinners, account for 10% of all preventable adverse drug events. In this particular study, 50% of all patients differed from their doctor in term of understanding how they we supposed to take the medication. In other words, one half of the study population was taking a Warfarin, a medication with serious side effects, incorrectly.

These finding are consistent with another 2006 study of physician-patient communications during primary care visits in which the physician prescribed a new medication. This study found that physicians:

• Did not tell the patient the name of the new medication in 26% of the cases
• Did not explain the purpose of the medication to patients in 13% of cases
• Did not tell patient about adverse side effects of the medication in 65% of cases
• Did not describe to patients how long to take the medication in 66% of cases
• Did not tell patients the number of pills to take in 45% of cases
• Did not tell patients about medication dosing and timing in 42% of cases

Doctors rely on patients to accurately tell them what prescription medications — and what dosages. In instances where the patient sees another doctor unfamiliar with their medication history, not knowing the name or dosage of a medication can cause serious problems. This is because “the other physician” may unknowingly prescribe a course of treatment that may have an adverse interaction with the patient’s primary course of treatment.

Failure to Inform Patients about Abnormal Test Results

Failure to inform a patient of an abnormal outpatient test result is another example of a serious error. The “failure to inform” rate was estimated at 7.1% in a 2009 study of 5,434 older adults in 23 primary care practices. “Failure to inform” rates for practices in the study ranged from a high of 26% to 0%. In cases like cancer where time is of the essence, any delay in treatment can have serious consequences for the patient.

Today hospitals are under pressure from regulators and payers to clean up their act with respect to inpatient quality, safety and outcomes. As hospitals employ more one time private practitioners, the list of quality, safety and outcomes issues faced by the hospital will grow to include issues like those described here. Issue previously handled by physicians in their own office.

My advice to hospitals? Know exactly what you are buying. Conduct a communications audit of the physicians in the practice before you buy. You will be glad you did.

Sources:

Schillinger, D. et al. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? Advances in Patient Safety. 2007.
Tarn, D. et al. Physician Communication When Prescribing New Medications. Patient Education and Counseling. 2008.
Casalino, A. et al. Patient-Physician Communication about Out-of-Pocket Costs. JAMA 2003.
Casalino, L. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. 2009.
Preventing Medication Error. Institute of Medicine (IOM). 2006.,

Patient-centered Care and Physician Use of Social Media

I came across a piece in USA Today this week about “Doctors who are not on Facebook, Twitter and blogs risk becoming irrelevant” by Kevin Pho, MD, author of the KevinMD blog. This article prompted the following post.

The Patient-Centered model of care is predicated among other things on physicians factoring in knowledge of the “person behind the patient” into their treatment.   That’s means understanding and, where practical, honoring the patient’s beliefs, values and preferences.   In order for a communication between a physician and person (patient) to be “patient centered,” it must be congruent with patient preferences for how they want their physician to communicate with them.

So Just How “Patient Centered” Is Social Media?

Let’s consider test result reporting to patients.   If you are among the 5% of patients who (in very recent large-scale studies) indicate they want to receive normal test results by e-mail for example, e-mail results reporting is very patient-centered. Only 1% of patients prefer receiving abnormal test results via e-mail.   Social media, e.g., e-mail, is not very patient-centered however if you among the other 95% of patients that prefer to be notified of normal and abnormal test results by telephone, snail mail, or in person visits with your doctor.   I understand that e-mail is not necessarily considered “social media” like Twitter, Facebook, or blogs, but it is the only “indicator” we have to date in the research literature.   I also acknowledge that non-physician blogs and social networking sites such as PatientsLikeMe show great promise in building self care management skills, confidence and support among people with similar chronic disease conditions.

Implications?

This is not to say that physicians should avoid social media when communicating with patients.   I am just saying that, according to the evidence, social media is not for everyone at this point.    No doubt patient preferences involving social media will evolve with the development of new applications and privacy protections…but we are nowhere near that point yet.

From my vantage point, when it comes to communicating with patients, physicians’ time would be much better spent by:

1. Learning what their patient preferences are (with regards to communications, medications, exercise, nutrition, etc.).
2. Tailoring conversations with patients during office visits to their preferences and concerns. The evidence shows that by doing, physician can more effectively engage patients, increase patient adherence, reduce cost and improve outcomes and satisfaction.

I have yet to see large scale studies that shows how social media can do that.