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Curbside Consult with Dr. Jayne 6/6/16

June 6, 2016 News 3 Comments

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I’m a little slow on the typing this week, owing to a little craft-related accident. Although I expect to make a full recovery, I’m glad I’m up to date on my tetanus immunizations. I’m also glad I wasn’t crafting alone, so I had someone to drive me to my office so my partners could get a good chuckle about taking care of me. I was selected to receive a patient satisfaction survey and was happy to give them five stars. My crafting buddy got a kick out of seeing what happens when a doctor phones ahead for their own urgent care visit and offered lots of moral support (and only a few snarky comments).

Fortunately, I had finished most of what I needed to do this weekend before the incident, so it was a good excuse to catch up on the Netflix mailers that have been mocking me from across the living room. I also spent some time editing a research article that a friend is working on. It’s around the release of test results (laboratory and radiology/diagnostic) through patient portals and how their use is impacting patient engagement and provider behaviors.

When I first started working on patient portals about eight years or so ago, there was a lot of anxiety about releasing results directly to patients. In particular, my physicians were concerned about being able to review results first and contact patients before they saw them on the portal. Our hospital brought in some “hired guns” to help us achieve clinician buy-in – a couple of CMIOs from hospitals that had done this previously and lived to tell. We ended up setting a pretty significant delay on the release of results to make sure we allowed for plenty of time for physicians to contact patients first.

A lot has changed since then, including physician attitudes. Meaningful Use set the expectation that visit summaries would be available to patients fairly quickly, and physicians were forced to respond. Additionally, organizations are sending full visit notes and other documentation to the patient, not just lab results or summaries. With my trip to the urgent care today, I had my visit note within an hour of arriving home. My colleague surveyed physician leaders at various institutions to obtain data on how they are releasing results. The data is interesting. Most hospitals still have delays, which coincide with the deadlines imposed by Meaningful Use. Some release inpatient labs sooner than outpatient, and some don’t release inpatient labs at all. The majority of respondents said that they don’t release sensitive lab results – sexually transmitted diseases, drug testing, genetic testing, etc.

Organizations were fairly split on the release of pathology results – some don’t release them at all, and others release but on a longer timeline, usually seven to 10 days. Several responded that they release but only based on a manual release process – no automatic triggers. A couple of respondents said they didn’t know what their institution’s release policy was and one respondent said they didn’t think there was a policy in place. One reply discussed the hospital’s plan to completely revamp their release strategy, with plans to immediately release non-sensitive blood testing and plain film radiology as soon as those tests are flagged with a final status.

In talking to my friend about her work trying to round up the results, she had some interesting stories to tell. Although many of the stories are anecdotal, they are interesting nonetheless. One hospital had decided to go to an immediate release policy and then had to go back on it, blocking release of labs from the Emergency Department. It seems that patients were getting their results from the lab before the ED staff had a chance to review and act on them, and there were several incidents of patients becoming aggressive because they knew results were available and hadn’t been addressed.

In addition to changes in how physicians address test results after the fact, the paper notes some changes to ordering behaviors. Respondents stated they were more likely to counsel patients on the potential significance of results at the time of ordering, so that the plan would be in place before the test was ever ordered. This would seem to be a big win for patient engagement, as well as for practice efficiency. I know I tended to do this when I was in traditional primary care practice, because shared decision making is a lot easier in the exam room than over the phone.

Patient portal access for adolescents continues to be a major issue, with some organizations locking out patients from ages 12 to 18. Some allow limited access for parents during the adolescent period, where others allow full parental access but require the adolescent to consent to it. Nearly all respondents grappling with the adolescent issue cited the concern that a chart with blocked information or hidden information would be a patient safety issue, although they acknowledge that there are state laws and other regulatory factors at play that make the situation difficult.

One of the other questions asked in her survey was around the ownership of the decision to release or not to release data, and when. She specifically asked whether that has changed since the institution of the patient portal. Most organizations have made changes to their release strategy and I would bet these strategies continue to evolve. In my opinion, the most significant change has been the addition of patient/family advisory groups to the discussion. We didn’t see that very often in the early days and it’s a welcome addition in my book. I haven’t edited a scholarly article in a while so it was a nice exercise, and hopefully my penmanship wasn’t too atrocious with my stiff index finger. She’ll be submitting it formally in a few weeks and I can’t wait to see it in published form.

For me, though, it’s back to Netflix. What’s your favorite streaming series? Like to binge watch? Email me.

Email Dr. Jayne

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Currently there are "3 comments" on this Article:

  1. On June 2, at the ONC Annual Meeting, Karen DeSalvo began the government’s pivot away from institutional EHRs by looking forward to “longitudinal patient records”. This follows on the heels of recent publications in the NEJM on Patient-Centered Health Records. The ideas in this post seem anachronistic from a patient-centered perspective. Would an institution delay or restrict updates of a patient-centered health record for fear that a patient would have access? With a patient-centered or longitudinal health record, who decides what delay or patient access restriction applies??

    This post highlights another reason the EHR model is on the way out.

    Adrian

  2. Very interesting! Yet another example of “we don’t know what we don’t know”… I find the “family management” of healthcare in the “electronic world” a bit challenging (expanding on the adolescent comments above)… As a both a child and a parent, and furthermore a spouse, we struggle constantly with health management (from scheduling to billing and everything in between) across our family in ways we never did before in the “paper world” (and “privacy” concerns of the digital age)… Whereas we normally had one designated family member for various things healthcare related, it’s almost impossible to do today without using eachother’s logins, etc., from Doctor to Dentist to Pharmacy to Lab…







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