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Curbside Consult with Dr. Jayne 10/24/16

October 24, 2016 Dr. Jayne 5 Comments


One of the family medicine journals recently published an editorial on preventing diagnostic errors in primary care. It advocates using diagnostic checklists and clinical decision support tools to make sure an appropriate differential diagnosis is considered. Although checklists can be helpful to make sure you arrive at the most likely diagnosis, sometimes physicians just want to know whether we were right and what happened to our patients.

Now that the MACRA final rule is out, we know that HHS plans to continue monitoring to see if EHR vendors are guilty of information blocking. I know I’ve mentioned this before, but I’m still waiting for someone, anyone, to come after the hospitals and health systems that are guilty of information blocking. Especially when treating a patient with an uncommon presentation or a rare diagnosis, follow-up is needed to understand whether the diagnosis was accurate and whether the treatment provided was appropriate or whether there was something more beneficial that could have been done. It’s also important for me to know whether my patients have any complications as a result of my treatment.

This week, I had a couple of rare cases and wanted to track down what happened. In both cases, I had to transfer the patient for further care – one went to a local community hospital where I was an attending physician for many years and from which I continue to receive (erroneous) patient test results. The other patient was refused by the community hospital due to the nature of his condition, so I had to send him to a tertiary referral center where I haven’t been on staff but where I know for a fact that I am in the referring physician database.

In each case, I called report to the facility, giving my name and the pertinent information on the patient’s condition. I also sent copies of the patient’s urgent care evaluation note and the CT scan performed at my facility, both with my name and credentials.

In both cases, when I tried to call for follow-up, I was stonewalled. One facility had the audacity to tell me that, “We have no idea of knowing you are who you say you are” despite the fact that I could accurately give them the patient’s name, date of birth, time of the transfer, and name of the nurse I spoke to when giving report. I urged them to look at the transfer and admission documents to verify my status.

The other facility told me they couldn’t even verify the patient had been admitted “due to HIPAA,” again despite my providing all the information including the name of the attending physician who agreed to assume care.

Last time I checked, HIPAA allows the disclosure of protected health information for treatment, payment, and healthcare operations. Even if you wanted to argue that I was no longer treating the patient, the definition of healthcare operations clearly includes: conducting quality assessment and improvement activities, including outcomes evaluation; care coordination; evaluating provider performance; and certification activities. Despite it being around for two decades, HIPAA is still misunderstood and various entities continue to cite it as a reason to prevent information sharing.

How is this not information blocking? Sharing information verbally and in writing is the precursor to interoperability. And in areas of the country like mine, where there is no consistent platform for EHR-based interoperability, it may be the only way to get information. Where are the HIPAA police when you need them?

If healthcare entities cannot understand a regulation like HIPAA after 20 years, how can there be any hope of everyone understanding MACRA and all its successor requirements that go into effect in a little more than two months?

Hoping that I was just dealing with overworked floor staff who may not understand the nuances of clinical follow-up, I decided to go up the chain and see if I could find another way to get the information I need. I ran a couple of reports out of my EHR and found out how many patients I personally referred to the hospitals in question, as well as how many patients our practice overall had referred in the last year. Knowing that the hospitals have programs where community physicians can have access to their clinical data, I decided to ask for courtesy access. If that failed, I planned to cite the transfer volumes and make a compelling case to be able to access the records in the name of practice-related quality improvement activities. We’re the largest independent urgent care in our metropolitan area and we generate substantial referral volume, so I was hoping they’d bite one way or the other.

Both of them gave me the same response. Unless I apply for and obtain medical staff privileges at the hospital, they have no way to give me access. Being on staff means that you have to actually admit or otherwise attend to patients in the hospital, which isn’t covered under my medical liability insurance since I’m no longer practicing traditional primary care. It’s the reason why I resigned my privileges during my most recent reappointment process to the previously mentioned community hospital, because I couldn’t meet the ongoing requirements.

Hearing the tertiary referral hospital cite the medical staff requirement was especially funny since I know for a fact that they have hundreds of students, researchers, and quality review staff who have access to their clinical data repository, as do payer claims auditors and others. I’m familiar with the fact that they have robust methods for auditing chart access since I helped lead the consensus-building around those methods in my former life. I may also know where the proverbial bones are buried since at least one of their executives worked to stymie our efforts to build a health information exchange.

Yet regulators are going after EHR vendors rather than going after hospitals that refuse to share information with relevant physicians and even with patients themselves. The same hospitals that have accepted countless millions of EHR incentive program money in recent years and who hope to continue drawing down federal dollars continue to be part of the problem despite some feasible solutions.

I’m not letting this go, but plan to continue working may way up the chain at both hospitals. I’m also going to ask at a couple of other area hospitals that receive our patients to see if they will bite and therefore create a precedent. I have a feeling I’m more likely to be blocked then allowed access to the clinical information superhighway.

How does your hospital handle records access and follow up for referring physicians? Email me.

Email Dr. Jayne.

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Currently there are "5 comments" on this Article:

  1. Incredible. So much for continuity of care. They need to go and reread HIPAA. Oh wait, I’m quite sure they haven’t read it in the first place. They’re just afraid. Sad, but true.

  2. They have read it, but their counsel tells them the best defense is stonewall all inquiries. When I worked for government, learned the hard way that there are very few regulatations, let alone statutes– that say health care information must be shared.

    Good luck chewing on this bone!

  3. My hospital system has community status, which means membership without privileges. Most of the primary care staff has gone that route, and that does give you the option for read-only access to the EMR. Do very many of them take advantage of that? A few from what I can tell. And no, there’s no option for read-only for someone who’s not at least a medical staff member, which requires the whole application and vetting-of-your-whole-life process.

    I occasionally have luck with Epic’s Care Everywhere, but for that the patient has to be in your home system. Then you have to create an “encounter”, and depending on the other place’s policy you may have to print a permission form for the patient to sign and scan it into your records. But sometimes it pays off very well.

    Is HIPAA really the problem you’re having? A little bit. But if it weren’t there they’d find other excuses. Data siloing is the bigger issue.

  4. I wish you well and encourage you to pursue the matter of clinical follow-up. One of the reasons we collectively pushed for EMR/EHR adoption was to enable such post-care (or even current care) learning, clinical improvement, and better outcomes for patients. Clearly the EMR is not the sole, or even primary prerequisite for clinical follow-up, but used correctly it could be important.

    In fact, I would go further. Why does it have to the physician who has to request this? I mean it’s always an exception right now, driven by the physician’s time and interest. Those are limited commodities.

    Perhaps we should have a system whereby clinical follow-up is always available to the physicians involved in the care plan. I have in mind a sort of “hot list” of recent patients and cases, proactively delivered to the physician. The physician would have to click to ask for the details, thus still giving them final control over their time and workflow. However if such a list were routinely available to physicians, perhaps we would start seeing those clinical benefits flowing to physicians, that they say they want from the EMRs.

    One of the weaknesses of the EMR system that exists is that many of the clinical benefits are only seen in aggregate, at the population health level for instance. This could be a way to deliver real improvements at the point of care.

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