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. 

The Three "P"s of Mayo--Patient-centered, Physician-led and Collaborative Partnership

Last week I attended the Mayo Clinic's Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don't know why the publicity folks were so intrigued, but for me Mayo's philosophy of "patient-centered, physician-led" care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target.

My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician's responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line. 

Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I'd seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound. 

Children's waiting area

Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I'll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.

Flu Shot Day

It's the time of year when my MA chases me around the office until I acquiesce and let her give me the flu shot. There is no rationale for this. I don't even mind shots but for some reason I put it off as long as I think it is safe. I feel the same way about clothes shopping, which is why I mostly do it on line. But no one ever died because they didn't go shopping for jeans.

So for anyone who has a reason for not getting the flu shot please watch the following. If you've already had yours, you might want to watch this anyway cause it's slightly funnier than placebo (and a little off-color):

And for those people who "never get sick" and therefore don't get the flu shot, please see this by Zubin Damania.

Thanks. (OK, now where did my MA go...)

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. 

Guest Blog: A Patient's EHR Point-of-View

Barry Comer, blogging at Thoughts/Rhythms, gives a poet's impression of the EHR experience:

In June of 1966, several crew members begin dying from a mysterious depletion of salt, extracted from their bodies. The crew’s doctor anaylizes post-mortum and discovers by instrument, the phenomenon’s cause. 

Of course this is the fiction in 1966, envisioned by Gene Roddenberry for the 23rd century. The imaginary “tricorder” in the doctor’s hands is for wishful dreamers and possibly envied by my physician, in 2012. 

With the introduction of electronic medical records (EMR) to the patient/physician dialog, neither the future nor a “diagnostician in a hand” have arrived. Clumsy to learn, intrusive in use, EMRs in form and function are short-reaching obstacles, that chart their course with manual input and uncertain results. 

Some tools in the 21st century disappoint and others appear with malice. Because EMRs are still untamed and newly minted, their usefulness arrives as a mixed blessing. 

They say, “time heals all”, but our relationship is in trial to stay in the moment.

My physician is intuitive, intelligent and listens carefully. She possesses a black belt

in medical counsel, that appears clairvoyant. Her holistic relationship to my body and mind is why I call her my doctor. The EMR pushes that trust backwards. It conspires to break her gaze from me and worse, has taken certainty of our relationship, into the “getting to  know you” process again.

Not only do I depend on her words, I put trust in her eyes. But when they stray, I feel the magic leave by the tiny keystrokes and space bar taps, filling the exam room. Our agreed upon relationship is breaking and hear it in her sigh.

This was not the future promised and feel once again, that some technologies are better left in clinical trial, with release contingent on both aesthetic and functionality. Without both, advancement seems muted by imagined giggling of software authors in the bushes. 

Not all things advanced by the goalkeepers make for better analysis and savings. Growing suspicious has been supplanted with hopeful resignation. It may get better and after all, 

I may just have a cold.    

Nostalgia and the Local Pharmacy

Recently a patient in our practice requested his Plavix renewal from a 90-day mail order pharmacy. When the "estimated" price came to $585 he decided to stop taking his cardiac medication. In exploring his insurance website I found that the actual cost would only be $200. In addition the company had a "Do Not Substitute" order on the prescription (something his cardiologist denies writing) and the cost of the generic is $28.59. Wow--the drug he almost quit taking because of the website price estimation was, in reality, 96% cheaper than originally thought. 

Contrast this with a phone call I received recently from Wish's Drugs, a local pharmacy here in Louisville. The pharmacist paged me on a Saturday morning regarding a patient's medication. I called the pharmacy and the pharmacist answered the phone(!). He suggested that my patient get a similar drug for half the cost of what I prescribed and asked if that would be OK. When I hung up the phone it struck me how pleasant that had been. Not just that the pharmacist was looking out for the interest of our mutual patient, but the call from start to finish--a real person answered the phone and it was the person I needed to speak to. Not only did I not push three different buttons and listen to three different voice messages along with a sales pitch for flu shots, but I immediately spoke to a person knowledgable and caring about my patient and her medical condition. Contrast THAT with the 90 day site where the patient, unknowing, was supposed to go back to his insurance web site, check the price of his medication and THEN go back to the pharmacy web site and decide that he could actually afford the medication because the real price to him would (only) be $200. No friendly pharmacist in that other state willing to make a phone call and get his patient a better deal on his medicine. 

It's not that I think mail order pharmacies are inherently evil, it's just that the service component is reduced to the patient. However, interestingly enough, the two studies I read regarding mail-order vs. local pharmacies [1,2] found patients are more compliant when they use mail order. Perhaps this is because when medicines are delivered right to the patient's door it reduces extra steps, making it easier for patients to remember and obtain their drugs?

In my experience patients enjoy the convenience and economy of getting 90 days worth of medication delivered to their mailbox but when there is a problem they are quickly frustrated by the difficulty of explaining to someone in another state what their needs are. As a physician, I am annoyed with the same difficulties, plus the frequent faxes asking about changing patients to a "cost-savings" alternative, something the patient is usually unaware of so we have to call him/her, ask their permission, explain what the change entails, etc. Just one more thing in my over-extended day that I don't have time for. 

Mail order pharmacies are not going away and local pharmacies where the pharmacist knows the patient and cares for him/her in a more intimate way are disappearing into distant, nostalgic memories. Given the studies quoted here, maybe that's a good thing. Does my desire for it to be different, for every patient to have the individual attention of the good pharmacist at Wish's make me out-dated?  



1. Schmittdiel JA. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.J Gen Intern Med. 2011 Dec;26(12):1396-402. Epub 2011 Jul 20
2. Duru OK. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010 Jan;16(1):33-40

Continuous Partial Attention

Continuous Partial Attention--while reading a blog post this morning that term jumped out at me. The last few weeks of juggling a laptop while talking with patients have made it obvious how easily distraction can take away from the doctor-patient interaction. Right now the computer interferes with my ability to give complete attention to my patients' stories. Did I have the same problem way back in third year medical school when my first ? I don't recall taking pen and paper in patient rooms back then, but do remember trying to juggle all the things I needed to ask--chief complaint, history of the present illness, past medical history, family history, medications. Then there were things that needed to be looked at--vital signs, physical exam, nurses notes, ER notes--followed by the assessment and plan. These were all foreign terms and workflows to me. Was I intensely listening to the patient then or more likely, worrying about what I'd forgotten to ask, or do, or write down or study? My earliest instance of Continuous Partial Attention (let's call it CPA so I don't have to keep writing that term) with patient care must have begun then.

Early in practice I found ways to control the CPA triggers--a snack of nuts or fruit around 10 am to keep my sugar from dropping out; keeping the phone on silent (there are medical programs on it that I use routinely so I can't leave it on my desk); using meditation techniques to bring me back to the patient if I find my brain wondering off; exercising and sleeping routinely so I have enough energy for my day.

It's not just doctors who have the CPA issue. Many times I recognize the same thing going on with the patient--the gentleman this morning who needed to be at work and was only half-listening to my advice regarding his medication and exercise compliance, the woman who thought bringing three kids to her physical was a good idea, the patient who was recently diagnosed with cancer and nearly oblivious to any other health concerns, or the husband with a terminally-ill wife paying little attention to his own health (or me).

Surely the CPA will fade away as I find a path to making the electronic record become as unobtrusive as the paper one once was (hint to IT dept--smaller tablets would help with this...just sayin'). In the meantime, one of the more important lessons on the EHR learning curve is finding a way to move the laptop out of the center of the conversation--figuratively and literally.