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Curbside Consult with Dr. Jayne 9/26/22

September 26, 2022 Dr. Jayne 5 Comments

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It seems like lately I have been seeing more of the patient side of healthcare than I care to. That trend continued this week as I was again pulled into the caregiver role. A close friend experienced an accident while far from home, leading to injuries that prevented them from traveling under their original arrangements. Initially, I was engaged to help arrange travel that would get them home quickly, while also accommodating medical needs. That was an adventure in itself, involving lots of phone calls, some hypothesizing about the patient’s condition, a remote airport, dense fog, and a circling plane that ultimately had to be diverted before making another attempt the next day. That kind of experience is certainly nerve-wracking for those trying to coordinate things from afar and even worse for the patient.

Because I wasn’t able to speak with the medical team at the hospital where they were treated, I was hoping to get a greater understanding of the clinical picture by reviewing the notes available in the hospital’s patient portal once the patient made it back home. Initially, I just had the information from the discharge packet, which was lacking some important elements, namely three of the four diagnoses that I expected to see based on the patient’s description of the situation and the other data on the discharge summary. However, there was an access code for the patient portal, so I was eager for the patient to login and take a look.

Unfortunately, there was a problem with accessing the portal, because despite keying in the access code and the patient’s demographic information, it wouldn’t allow us to proceed. We tried to make an account from scratch without the access code, and that didn’t work either. For some reason the system wasn’t able to validate the patient’s information. Of course, the patient knew their own demographics, and the date of birth and name were featured correctly on the discharge paperwork, so we could only hypothesize that the Social Security Number was wrong. Upon making it home, the patient called the portal assistance number on the discharge paperwork only to be told that no one could assist because it was a weekend. I joked that I hoped there weren’t any typos in the insurance information that was entered, because dealing with a denied claim can be a months-long challenge.

On Monday, the patient called the number given with the failed portal login message, and was immediately transferred not to a patient assistance line but to the hospital’s internal IT department, who couldn’t assist. After three more transfers and 40 minutes of being on hold, they finally hung up and called the Emergency Department directly. It turns out that there wasn’t a typo in the Social Security Number, but rather that it hadn’t been entered at all when the patient was registered by the Emergency Department. The receptionist was able to add it to the account, allowing the patient to finally access their information five days after the visit. We were able to see the patient’s Emergency Department progress note as well as the Radiology reports, but unfortunately there was no access to the images that would certainly be of interest to any physician with whom they’d follow up, given the nature of the injuries. There was no information on how to get the images, so we assumed there would have to be another phone call to the hospital.

On one hand, I wished the patient had known to request copies of the images while they were still at the hospital – but most patients don’t think of that, and a patient with a head injury who was having memory issues at the time definitely shouldn’t be expected to be responsible for that. The care team knew the patient was from out of state – in the facilities where I’ve worked in recent years, we’ve always been able to create a CD with images in that type of situation. It doesn’t sound like anyone offered that as an option, at least as far as the patient can remember. On the other hand, the patient doesn’t necessarily remember giving anyone a photo ID, which would be surprising in a hospital that’s part of a large integrated delivery network. At least they remember giving someone an insurance card, but all bets are off as to how the financial part of this experience will play out.

In looking at the Emergency Department note, its contents confirmed my suspicions about missing diagnoses. The physician mentioned several different findings that should have triggered additional diagnoses for the visit, but apparently didn’t. He also failed to mention the patient’s significantly elevated blood pressure and didn’t enter any comments for the patient as far as when they should follow up with someone, and what kind of physician would be advised. As a physician who has spent the last 15 years practicing in emergency care facilities, it was appalling. In every facility where I’ve worked, we’ve been encouraged to put all pertinent diagnoses on the chart and to ensure that there is a follow-up instruction noted for each and every one.

We can talk about patient engagement, quality transparency, and cost comparisons all we like, but in reality, all of that goes out the window when you require emergency care. This patient didn’t have the opportunity to shop around, to vet the qualifications of those that might be treating them or see what the cost might be for what is clearly going to be an out-of-network visit. They were prudently taken to the nearest emergency facility, which is the right thing to do when you’ve experienced head trauma, loss of consciousness, and blunt chest trauma. Unfortunately, what we call our healthcare system let them down, and without advice from their friend who happens to be a physician, they (like many patients) might be unsure of what should be done next.

The lack of follow-up is particularly concerning, especially since the patient was far from home, had fractures requiring follow-up, and the emergency physician provided less than two days’ worth of prescription pain medication. This kind of thing often leads to patients taking massive quantities of over-the-counter medications as a result and isn’t ideal in a patient with elevated blood pressures. Even if the Emergency Department had a policy to only give a set quantity of pain medications, there was no option given for local follow-up either. The patient is lucky they didn’t have complications, but their pain was poorly managed and I can’t imagine traveling in that state.

I’ve thought a lot about this situation the last few days, and particularly about the health system involved. Although the hospital was somewhat remote, the health system isn’t, and frankly I expect a little better from an organization whose core values include compassion and accountability, and whose website talks about advocating for each patient it serves. I’m glad I can help the patient navigate this situation, but the need to embrace a BYOD strategy (Bring Your Own Doctor rather than Device in this case) is a sad commentary on how patients experience healthcare more often than we think. I hope some hospital administrator reads this and questions whether this might have gone on in their organization, because based on my experience as a consultant, this situation is far from unique.

What has been your worst experience as a patient? How did you manage it? Leave a comment or email me.

Email Dr. Jayne.



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Currently there are "5 comments" on this Article:

  1. I’m an informatics doc, out of clinical practice. I had an awful experience about 6 years ago that wasn’t negligent care but I was…neglected.

    I was sent to an ED to be admitted after a CT revealed florid PE in both lungs at a local hospital. I was asymptomatic and the original event was over 2 weeks prior. I waited 4 hrs in the waiting room after triage, called my wife to bring me a sandwich. I considered leaving when I finally got called to a room in the back. The AC in the room was blowing hard and it was freezing; my wife had to come back with a jacket and proactively brought me dinner. I only briefly spoke with a resident who never examined me, no one discussed my plan of care, or reviewed my CT. They sent environmental services to try and fix the AC, no luck. They moved me to another ED room eventually. I asked why I wasn’t being admitted, they claimed no beds, but it turned out to be close to Hospitalist shift changeover so they wanted to wait for the night doc to come on and do the admit. After 6 hrs in an ED bed, a Hospitalist came down, did my H&P (ED docs never did), and finally I got admitted. At no time was I asked if I wanted food during the 10 hrs I was waiting. At some point I got a SQ shot of anticoagulant.

    It got worse, they put me in a bed that kept deflating and I wasn’t able to sleep. The only saving grace for being in overnight was the full-court-press of lab work and imaging; ultrasound found an occult DVT that was never symptomatic.

  2. How about this. Went to hospital for surgery pre-admit process. They had listed my primary doc as someone I never heard of. They corrected it, or so they said. A week later I had a follow-up visit with my primary. Came into the office with a walker and when she saw that she said “What happened to you?”. My guess is the hospital never notified the right primary, and the one that got the discharge message about me never told my real primary. By the way the surgery was scheduled some 4 months prior.

  3. Sadly, this is not surprising. I represent a solution designed to provide real-time AI driven clinical guidance for the highest-risk patients in emergency medicine, reducing Dx errors and uncertainty with clinical support for MDM. We have analyzed 24,000 patient encounters from 24 health systems, the average documentation compliance is 46% across 8 high risk presenting problems. All sites were within the same range of documentation, very little variation.

  4. Not my worst as a patient but as a caregiver. Last year my mom was rushed by ambulance to the ED, we didn’t know it at the time but she almost died on the way. At the first ED no doctors talked to my dad and none called me, despite us requesting information on what was going on. It took 2 days for her to get an MRI that indicated necratizing pancreatitis and then she was medivaced to another hospital who could provide a higher level of care for what she had. Again, no doctors talked to anyone in the family about what was going on until I called so many times that they had a med student call me back. No one gave us any info, even to tell us if we needed to come to PA to say goodbye. It was terrible. When I attempted to get proxy access to my mom’s MyChart account much like in your scenario they couldn’t match anything up despite me having the rigth info and my mom having an account. I finally had to fly to Philadelphia to advocate for her.

    While in the hospital their were multiple miscommunications between the care team leading to her being given food, which again nearly killed her. And when the health system’s EHR went down I had to have them put a sign on the door saying no food b/c they didn’t have a system to check and my mom wasn’t coherent enough to refuse. We finally learned towards the end of her stay that the reason we didn’t get any communication with the doctors is b/c of the COVID visiting hour restrictions. The policy had been that family was typically there during rounds, so they could be filled in from the doctor. But with the COVID visiting hours we weren’t allowed to be there. No one at the hospital thought about that, and frankly acted like I was crazy and overbearing every time I asked to talk to a doctor. At a few points I had to demand it. So we had zero access to her patient portal, zero communication from doctors, and mildly better communication from nurses. And they tried to discharge her to home b/c we were struggling to find a SNF with a bed (first time and hopefully last time filing a complaint with the regional QIO to prevent discharge). All while I was remotely working, taking care of my dad, and trying to advocate for my mom. Nightmare. The only upside is that my mom survived despite all odds and is now very healthy.

  5. “… I wished the patient had known to request copies of the images while they were still at the hospital…”

    I really have to question why ANY patient should have to take steps like this. It’s not a matter of a head trauma or not; it’s about the organization who provides care is entirely responsible for documenting that care.

    Ultimately, if the patient, the patient’s family or friends feels a need to do this? It’s about control and/or a lack of trust.







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