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Saturday, September 25, 2010

A surprise every 15 minutes

Every time I see patients in the typical ambulatory setting, I still marvel at how ridiculous our processes and workflows are. I have a practice which includes new referrals for complex problems and follow up patients, also generally with complex medical issues. For the patients who I see initially, I insist on record review before I will schedule them. Patients and physicians complain about this requirement and this generally impacts my patient satisfaction scores since all parties view this as a barrier to getting in to see me. Few appear to connect the dots that perhaps collection of information before the patient arrives at my office is critical for me making sure they are actually coming to the right place to address whatever problem they have.

The usual triage mechanisms in place involve the patient and someone at the other end of a phone line, generally someone with virtually no medical training. In our institution, the historical measure for productivity of those who received the calls and scheduled appointments was simple. How many calls can you handle per unit of time. Place any caller in any available appointment slot to keep the patients and their manager happy. Whatever information which might have been collected at the time of the call relating to the reason for the appointment was either not recorded anywhere or amounted to an obscure or inaccurate complaint, generally conveyed with tortured and often comical spelling. What the heck of someone drove five hours for a brief encounter with the wrong physician. We use tools which basically guarantee that this will happen.

I have wracked my brain trying to think of other industries with similar business models. There are some parallels with auto repair shops. However, they generally collect much more information regarding the challenge ahead of them than we do and manage time expectations much better than physicians. Imagine that, falling short of the bar set by auto mechanics. Perhaps I am being too hard on the medical profession. People are much more complex than cars and trucks. They cannot leave their body at the office and go on with the rest of their business using a loaner, at least no yet.

However, we are going to go nowhere until there is a broad recognition that we go about our business using a model which is fundamentally flawed. I should not use a process in my office which is based upon being surprised every 15 minutes. When I walk into a room with a follow up patient, I might have a hint of what I will face, but generally not. For my follow up patients with chronic and symptomatic disorders, I usually have implemented some treatment protocol some weeks in the past. Short of me calling each individual patient on a regular basis and asking them how they are doing, we remain blissfully unaware of what has transpired in the intervening periods between appointments. I actually do call patients but it is generally hard to reach people and it is not an efficient use of my time.  In a world of widespread and robust communication tools which allow us to collect all types of information automatically and in structured formats and which have been widely deployed in many industries, health care remains a remarkable exception.

At least part of the lag could be traced back to HIPPA. Perhaps more early adopter types might have tinkered with small scale projects to form the basis for larger and enterprise based tools. This has not happened, at least on any widespread level. I don't see MD/patient communication apps on my Droid phone. I do not think they exist for the iPhone either. The only way we will see the development of such tools  is for each large vendor to develop expensive enterprise patient portal tools which will need to comply with HIPPA, CCHIT, and whatever. These will be applications developed by committee and will likely serve everyone's needs equally badly. I will be surprised if they are robust and adaptive. They need to be both if they are to allow for the type of information exchange which will allow for physicians to recognize and be responsive to patient needs and to collect information is formats which will allow people and systems to review what they are doing and find areas for improvement.

At some point in the not to distant future, substantial numbers of patients will come from generations that have integrated electronic social networking tools into their daily lives and they will look at the way we do business now as some form of madness. Some already do. They are appalled that they cannot communicate effectively with me because they have to run the phone tree gauntlet or hope that I received the fax they sent. We surreptitiously use emails but since they are technically forbidden, the information never makes it into the actual medical record. It amounts to work arounds heaped on work arounds.

So we wait and continue to run our practices using the information tools of the last century and structure our days seeing patients in the context of agenda- less meetings and surprises every 15 minutes. Health care reform was most focused on increasing the number of people who get access to this dysfunctional system and paid scant attention to the barriers already in place which thwart efforts to re-engineer our processes. I am tired of bing surprised every 15 minutes, particularly when the tools exist to fix this problem right now.

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