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Curbside Consult with Dr. Jayne 3/24/14

March 24, 2014 Dr. Jayne 10 Comments

Mr. H posted some comments from the annual reader survey last week and one of the areas that people wanted to read more about was the patient experience of IT. As he mentioned, it’s difficult to get patients involved since they probably don’t read HIStalk, but the good thing is that all of us on the team are patients ourselves. I’ve had several recent adventures in patient engagement involving IT over the last few weeks.

Fail #1: I had mentioned before my ongoing issues with a large academic center and their patient portal. It’s a solid product, but I don’t think it’s being implemented or managed particularly well. I had an issue right after I signed up to use it where my last name was spelled wrong. It had been correct on the patient information sheet at the office, but was wrong on the portal. When I inquired about it via secure email, I was told I had “aliases” in the system and it couldn’t be corrected. A few weeks ago I made an appointment for my annual eye exam, and when the appointment confirmation came, I noticed my name was now spelled wrong in two different ways. Additionally, there is incorrect allergy information now posted.

There’s no way for me to fix it from within the patient record at the moment. However, it’s unclear if the product will allow that and they don’t have that functionality live or whether the product is that way by design. I called about getting it corrected and was told again that there are multiple “alias” accounts for me and that they can’t correct it. I have a serious problem with there being multiple accounts, especially since I’m only seen in one practice at the health system. Did someone create a duplicate chart? What’s going on? And why can’t they be merged if it’s a simple duplicate issue?

I brought up the fact that now I have incorrect health information present and specifically used the phrase “patient safety risk” multiple times. I asked them what the process is to correct the erroneous records and the answer from the portal team was “talk to your doctor.” I called the physician office and confirmed that my records are accurate in the source system. How can the physician be expected to clean up an erroneous allergy that she can’t even see?

I called the portal team back and told them that the source chart is accurate and asked them again for a process to correct it. They confirmed they have none. I then asked if I could withdraw consent for participation in the portal because I don’t want the erroneous information (how much else is there that I might not be able to see?) associated with my records or populated to another physician I might see in the future. Of course they have no way of closing my account. At this point it’s more an exercise in frustration rather than engagement. I don’t have hours to spend pursuing it, so I guess I will just let it go and continue to make sure the charts my physicians are using are accurate.

The bottom line is that systems (both the actual software and the policy/procedure associated with it) need mechanisms to handle issues like duplicate patient accounts, demographic errors, and especially medical errors. I’m floored that a major institution would be so clueless. After all, they have wait time billboards for the emergency department and sponsor the local sports teams, so they must be good, right?

Fail #2: This one is wrong on multiple levels. I went to a new physician for a fairly uncomplicated skin condition last December. Although I could have treated it myself, I’m not comfortable with calling out my own scripts and figured it would be good to establish myself as a patient in case I ever really need to be seen. This was in December. Last week I got a bill from the reference lab for the same date of service as my visit but for a surgical pathology charge. I called the ordering physician’s office and explained the bill and had them look in the chart.

Sure enough, there were results on my chart, but no record that I had been notified. Had they bothered to inform me of the results attributed to me, I could have told them that there had been an error. The staffer informed me that “it was benign, so we don’t call” and I let her know that “no news is good news” went out decades ago. She went on to look through the chart and saw that the lab had faxed (who still faxes these days?) a name discrepancy report. Apparently the name on the barcoded sample and the name on the electronic order the lab received were different, but the office corrected it incorrectly. I requested a call back from the physician, which I’m still waiting for.

I don’t want to get sent to collections for a bill I shouldn’t have received, so I called the lab. While on hold for 40 minutes, I had plenty of time to think not only about the potential source of the error (human error NOS, multiple episodes, probably staff had two patient charts open at the same time) but also about why it took 90 days to get the claim adjudicated and a bill to the patient. If we had real-time adjudication at the point of care, I could have handled the entire problem at the check-out desk and the sample would have gone out correctly. When a person finally took my call, I told them that I didn’t have a skin biopsy and wasn’t going to pay for it. They were nice about it and said they’d place a call to the ordering physician and get it taken care of.

My hospital is self-insured, although we do have a benefit administrator who processes the claims. I’m sensitive to the fact that the physician compensation model (small-business “eat what you kill”) has providers directly paying for the insurance premiums of their office staff because I used to pay those premiums myself. I wasn’t about to let $300 in erroneous payments go by, so I called the benefit administrator. The representative I spoke to told me that the physician performed a biopsy on me during my visit and I must just not have been aware.

Seriously? I guess I not only slept through the biopsy, but also the informed consent process and the actual consent form itself. It took me a full five minutes to convince her that I did not have a biopsy. I also told her that the office was aware of the problem and had admitted it, that I was just letting the insurance team know so they could recoup the payment since we’re self-insured and with the rising cost of health care, etc. She then helpfully let me know that they actually paid over $600 because there was another claim for a second biopsy I wasn’t aware of. Since it was paid in full, I didn’t receive a bill.

She admitted there would be no way to know it wasn’t accurate since it was the same date of service as my actual visit. I told her that’s why I was calling, to make sure that the payment was disputed so that the money would go back into the insurance pool because otherwise they’d be unaware of the problem. That’s when it got even more ridiculous. She told me that basically it was my word against the physician’s claim, and that unless I wanted to pursue written documentation of the error, there wasn’t anything they could do. She couldn’t provide a form or documentation of the actual information she needed – she was basically saying that there is no way for a patient to easily dispute a claim.

I reminded her (since she works for the benefit administrator and probably isn’t aware) that we are self-insured and I was trying to do the right thing getting the money rightfully returned. I let her know that the lab had already reversed my portion of the charge and at this point the easiest thing for me to do as the patient was to walk away. After all, it’s not MY $600 that was paid out (although at some level it is) and I had already spent over an hour trying to pursue this and now she was asking me to pursue undefined documentation that they’d probably reject anyway. I asked if there was any mechanism for them to reach out to the physician (after all the insurance fund was the one that was wronged) and she said I’d have to provide the phone number and she’d try to call if she could. I was surprised by that (they should have the phone number since the provider is in network) and interpreted it as her attempt to just get the patient off the phone and move on. I doubt she’ll ever call.

What’s my point here? The patient experience still stinks and it’s not all due to technology. Although my first tale of woe has a distinct odor of an IT nature, people are unwilling to address it. Heck, they didn’t even try to play a “known issue with the vendor, blah blah blah” card — they just said there was no way to fix it. The second scenario is strictly human error. The office put the wrong name on the requisition and filled out the name discrepancy form incorrectly. But because all the technology components were met (CPT, ICD, DOB, MRN, insurance information) the failure wasn’t detected.

It could have been mitigated by IT, however, with the use of real-time claim adjudication and the immediate collection of the patient balance. On the other hand it could have also been mitigated by a direct pay method of funding healthcare, where I would have been presented with a bill to review at checkout and then either paid it or disputed it rather than sending it to insurance. That’s the way medicine used to work.

To put the onus on the patient to correct either of these errors is wrong. We should be bending over backward to make sure patient information is correct and that there are processes to handle incidents like these. We’re all patients, and someday that could be us on the other end of the phone. There are other elements here, too. What if that biopsy was melanoma? Then that information would be in my claims data and that would be another nightmare entirely to try to correct.

At the end of the day, patients want physicians and other health professionals to be accessible. They want them to listen. They want the office staff, hospital employees, and anyone else they have to interface with (insurance, lab, etc.) to take care of their needs without acting like they’re in a hurry or pushing back. They want to be treated fairly and have accurate records. All the technology and the bells and whistles are nice, but they’re secondary for the most part. Many of us would trade it all for a physician who had more than six minutes of time to address our needs and an office staff that was pushing for us rather than pushing paper or the electronic equivalent.

Email Dr. Jayne.

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Currently there are "10 comments" on this Article:

  1. Great post, should be required reading for everyone. I’ve worked in HIT for 24 years, and I, too, had a similar experience where the technology, in theory, should have been able to do the job, but the human factor in the process failed miserably. In my case the clinical personnel were wonderful and did all they could to make sure things were done right, but the system implementation was poor, bad assumptions were made about workflow by the developers, and the configuration made doing the right thing not as obvious as it should have been.

    I think if the 25-40 year olds actually doing the development and implementation needed as much health care as those of us 50+, it would be quite a different story 🙂

  2. Good for you to try and fix each heinous goof. I’m working hard to fix our own patient reconciliation process because that level of database untidiness just doesn’t sit well with me. The billing insanity just boggles my mind.

  3. It is through these type of experiences that the system can be really understood for the mess that it is and made better (this will take many years).

    Al Lewis (and his team) do a great job evaluating and commenting on questionable outcomes data in the pop health arena. Is someone evaluating and grading (in a systematic process) the patient experience with the actual names of the health providers being revealed?

  4. Three two events that stick out in my mind:

    In the hospital (Meditech) – transferred to Recovery after 5pm Pharmacy close. Somehow something got mixed up…and in my new location the Pyxis machine did not have me listed…hence my pain meds could not be dispensed on time. You don’t mess with a patient needing pain meds – so RN just pulled them out under another patients name (so she said..and coincidentally was in the middle of a meds OE project at my employer).

    Second was when I went to NP to get a prescription filled – requires 2x/year blood test to get it…didn’t have that done so NP was going to give me a 1 month supply until the bloodwork came back. The practice is on Epic. The NP was frustrated – first time entred script she chose a Pharmacy from a state 1000 miles away (same name town). So she had to delete and start again. Second time she messed up on Dose…so had to cancel and start again. 3rd time she entered and sent it electronically…with 11 refills. She said she wasn’t doing it again, and she’d put needles under my finger nails if I refilled it again.

    Another time my family member went from ER –> ICU –> Floor. Every encounter they asked about allergies. Finally I said “aren’t you keeping track of that somewhere?”…RN said “yes, but we don’t trust the system so we ask every time”. Same hospital also gave family member an unnecessary CT (MD was livid…too much radiation)…they had paper charts and clerical transcription of orders into their OE system.

  5. Dealing with healthcare insurance is a nightmare. An average doctor visit for me requires the transaction to be handled by someone an average of 8 times.
    1. Make appointment and provide insurance info.
    2. Check in for appointment and update insurance info.
    3. See provider and capture clinical info.
    4. Billing takes clinical and insurance info and submits claim.
    5. Insurance processes and sends results to provider.
    6. Provider billing sends me statement.
    7. I review statement and pay, if necessary.
    8. Provider billing processes my payment.
    And in this case, the provider billed the wrong insurance. BCBS Anthem, not BCBS Arizona! Gotta start the billing process over. Do not pass Go. Do not collect 200 dollars!

    I find this process outrageous as a patient and I can’t imagine the frustration the providers feel that deal with insurance companies. High overhead to deal with insurance. Delayed payments. There are much better proven models for dealing with this problem. Unfortunately, insurance companies here are getting in the way. I’ve dealt with this issue from the IT side off and on for 40 years now, and insurance companies still control the providers and patients. At least some people are starting to talk about the solution to this mess.

  6. Good post. But the question, Dr. Jayne, is where were the clinicians in leading the implementation of the portal? Your portal experience is a bad one. But as a physician IT lead, do you have clinicians overseeing governance on something like that?

  7. Amen Sister! Things like this never cease to amaze me (although after all I’ve seen I too wonder why I let it “bother me”…) Just another example of why the “business of healthcare” is an oxymoron…

  8. @Samantha – this is a portal at a large academic medical center where I am a patient, not at my hospital. Knowing what I know about them, however, I would bet money on the fact that they had minimal to no clinician involvement. There are still quite a few hospitals and health systems out there that don’t see the value of clinician involvement or if they do, don’t have the right kinds of processes in place to be successful.

  9. And, I would add, staff involvement. In Old Pueblo Old Timer’s post, 7 of the 8 steps in the process are managed by the staff, not the provider. The front desk and billing staff are the ones who could have predicted the errors, but I’m betting they were not consulted at all.

  10. To me, the issues you describe are ones of character….that are then exacerbated by technology. Attitudes of ‘get the patient off the phone’ and ‘just walk away, it’s paid for, why are you complaining’ just show that society has changed quite a bit. The first commentator’s statement about working with certain age demographics is spot on. Technology is not a panacea and at times reflects our values……

    That’s why having some wisdom at the tiller of the implementation of technology is so important. Wisdom comes from intelligence and experience, which usually takes time. Each industry using IT should realize IT is a tool in their industry, not the industry (unless they are in the IT industry, but then the tool maker needs to understand the environment in which their tool is used). My biggest knock against Health IT is that many times they lose that understanding of where they actually fit into the larger Healthcare Industry picture.

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