Curbside Consult with Dr. Jayne 1/28/19

I had a particularly gruesome Sunday in the urgent care trenches. Not with the expected cases of influenza, but with people behaving badly.

It has been years since I worked in the big-city emergency department, so I never dreamed I’d be searching for handgun-related ICD-10 codes at one of our sleepy suburban urgent care locations, but there I was today (in case you are curious, it’s the Y22 series of codes for handgun discharge, undetermined intent.)

These are the days you want to just head home, drink an adult beverage, and relax. But that’s hard to do when you are two hours past closing time and still seeing patients who waited until the last possible minute to be seen. Woman with the toddler that fell of the sofa and hit his head on the coffee table — no worries, we got this. Man who has been vomiting all day but waited until after a certain TV program was over before he came in — not so much. (Note for the future, we have large, flat-screen TVs in all our patient rooms and you could have been watching your show with some IV fluids and good drugs rather than vomiting into a trash can at home.)

I had several patients get mad that our independent urgent care is not part of the big health systems and doesn’t share data with them. It’s hard to explain to information blocking to patients, especially when it’s their much-loved hospital’s policy that we can only fax information to their practices and can’t send anything electronically. We can’t even get a directory of fax numbers for the owned practices or employed physicians, requiring us to call each office to track down a fax number if we don’t already have one in our file. If they won’t even receive our information, you can guarantee that they aren’t going to share theirs with us.

I experienced this acutely earlier in the weekend, when I had to refer a patient with a new cancer diagnosis and the potential need for an emergent surgery to the emergency department at one of those local powerhouses. I called six hours later and asked to be transferred to the nursing unit for patient X, only to be told “we don’t have her” by the switchboard. Apparently, that’s code for “she hasn’t been admitted to our facility” and the central patient directory service was unable to tell me if she was still in the emergency department.

It wouldn’t be unheard of to spend many hours in the ED during peak influenza season, so I asked to be transferred. There I was told that not only did they not show her as a patient, but they couldn’t tell me if she had ever even arrived because “we can only see patients in the system for up to two hours after discharge.”

I asked to speak with the charge nurse and summarized the situation back to her, saying, “Let me make sure I understand. She hasn’t been admitted and no one can tell me if she ever even showed up because the computer restricts access by ED personnel after two hours.” She confirmed that is what happens, which just floored me as a referring physician.

When I called the ED prior to the transfer to tell them about the patient, I had given the name of the patient’s surgeon. Since I know the surgeon well, I decided to call her to find out what was going on. It turns out they didn’t even call the patient’s attending surgeon, and you can bet that my colleague was livid when I called her to find out what was going on. Since she’s a faculty physician, she immediately accessed the EHR and I could almost hear the steam coming out her ears. Not only did they not call her, but they called a surgery resident to assess the patient in the ED. That resident in turn called the on-call surgeon (on-call for patients who don’t already have a surgeon, that is) rather than the patient’s surgeon. The on-call surgeon decided to send the patient home.

The patient had a couple of critical lab values and some ominous ultrasound findings, yet there was no consultation note from the surgical resident and no ED physician note in the chart to help anyone understand the thought process. We’re not sure what the patient understands about her care and what she thinks about being referred to a general GYN for follow-up care rather than the GYN-Oncologist she needs.

I’ve been trying to call the patient for two days. I’m sure she thinks her surgeon and I are either incompetent or clueless since we’re the ones that referred her to the hospital for potential admission and a possible procedure. She hasn’t returned my calls and I feel terrible. These kinds of episodes are becoming more and more common in our healthcare non-system.

At least in this case, I’m eternally grateful that my colleague was able to pull up the EHR chart (such as it was) on her phone while at her daughter’s sports practice so that we would at least know that the patient made it to the hospital and had some additional testing. Hopefully her office will have more luck reaching the patient than I have.

How different things would be if we had actual coordination of care and information sharing. I sent the patient to the ED with paper copies of all the tests we performed at our facility, along with a CD copy of her imaging studies. I wonder if the hospital even looked at what I sent (they certainly didn’t pay much attention to my referral report) or if they just started over? Our practice requires that the “business end” of each patient chart is complete prior to discharge – vital signs, exam, procedures, assessment, and plan. For patients referred to another facility or transferred by ambulance, we have to get the entire chart done and printed to go along with the patient. Even though the ED in question uses scribes, the note still wasn’t done more than two hours later. Despite every clinical employee having advanced communication devices on every shift, they still couldn’t make the right phone calls.

In this situation, I don’t even have anyone to complain to or share concerns with since I’m sure they don’t really care what a lowly urgent care doc at a competing facility thinks. All the technology in the world won’t help when you don’t have the right processes in place or the staffing isn’t optimized to support people doing the right thing. Unfortunately, the patient suffers. I’ve got seven more shifts before I head to HIMSS and I certainly hope they’re better than this one.

Have your own terrible tales of information blocking? Leave a comment or email me.

Email Dr. Jayne.