麻豆传媒

Every morning when we arrive at work (and sometimes before we even get there), we are met with a surprise -- new messages in the in-basket folders of our electronic medical record.

Many of these are incredibly useful and clinically important: copied charts from our colleagues who have seen our patients in consultation and for ongoing care, results from labs or imaging we did in previous days, messages from our patients that will lead to better care or a change in management. But then there are those in-basket folders that seem not all that useful.

One in-basket folder I have seems to be made up almost exclusively of messages and emergency department visits related to patients I've never met. Apparently, somewhere down the line, someone can make a decision that I'm a member of the care team, for no particular reason, whether I want to be or not.

These are often patients who have never been seen in our practice, never been seen in our hospital, have no reason to think of me as their doctor, and wouldn't know me if they bumped into me on the street. But somehow, somewhere, something happened, and now, like it or not, every time something happens about one of these patients, I've got to know about it.

There was one patient where it seemed like a lot of really important things were happening, and I tried reaching out to our IT team to find out how I got connected to it, but they seemed to think it happened outside our institution, probably back at the referring institution or at the level of the insurance company. It felt really uncomfortable seeing all of this information, not only from a privacy perspective, but that there was no one I could reply to and say, "Please stop; please send this to the appropriate person; maybe you want to check with the patient and find out who they really want this information going to."

Sometimes it's not that important, a notification that a patient was seen at an outside orthopedist practice, and this information was shared through a network with everybody associated with this patient. Or the pharmacy had decided that I needed to know that this patient had received an RSV vaccine at their facility; please reconcile it with their chart.

And sometimes it reveals the many ways our system fails patients, how the promise of a connected healthcare system and a truly integrated electronic medical record is failing us all.

One of these patients, whom I've never met, has somehow electronically elected to have me receive information on every one of their emergency department visits. And they seem to go to the emergency room a lot. During a recent 2-week period, I counted 15 emergency department visits to a couple of outside hospitals that were connected through some electronic registry, meaning that sometimes they went to more than one emergency department a day.

A lot of what is downloaded is templated information -- a notice that the downloaded notes may not be formatted correctly, or vast data dumps of vitals, chart notes, labs, imaging, discharge planning, medications, counseling, and patient education. One of the downsides of these data dumps is that you somehow feel obligated to read through them, maybe out of prurient interest, maybe in the hopes that if one day this patient comes to see us we can have a better handle on what's going on. Maybe they've signed up with our practice as a primary care provider and just haven't made it in here yet.

But most of the time it almost feels like an invasion of privacy to read these things, and if they really are not our patient, I think the advisable thing to do is delete them, since there's no way we can reply to them and say, "Please, cease and desist."

Interestingly, for this one particular patient, I got to see the dozens of times that they were advised to stop smoking, to eat a healthy diet full of fresh fruits and vegetables, to take their medications as prescribed, to stop using drugs, to keep their mental health appointments, and to follow-up within 1 week with their primary care doctor. I also learned that they were offered counseling, education, and referrals, none of which seemed to alter the course of their clinical care over the current admission, nor in the subsequent ones.

I think of the waste that went on here, that nobody was able to intervene with this high-utilizing individual and prevent all of these non-urgent emergency room visits, each of which entailed interactions with dozens of ED providers and the spending of countless healthcare dollars. One of the triage notes said the patient had come to the emergency department after an altercation with their significant other, who had slapped them across the face, and yet somehow this led to a peripheral IV being placed, labs being drawn, X-rays and CT scans done on far too many body parts, and an EKG being performed. And more.

Surely we can do better. I know it's a challenge in the midst of all the chaos and pandemonium of the emergency department; we have similar issues at our own practice where discontinuity and disorder reign and things don't always function as they should. But perhaps we can put in guardrails, use smarter systems to detect patterns and prevent over-users of resources from over-using, and help them figure out how to have the healthcare system more closely align with their best interests.

Sending it to me, someone who doesn't know them, clearly isn't the best solution. At least consider opening up a communication channel back to them, so I can point out that while they may think they're sending this to someone who's involved in the care of this patient, they most definitely are not.

And then, maybe then, they can do better. So our patients can do better.

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