This week’s encounter with Big Health System brought additional frustrations, along with a profound desire to sell them consulting services.
My appointment was scheduled with a nurse practitioner. It was supposed to be set up with a link to an imaging service. The plan was to see the provider first, then have the imaging, then go back to the provider.
When I stepped off the elevator, I had my choice of two check-in desks, one for the provider and one for the imaging department. Since my appointment was with the provider, I went there first. I was told that I needed to go to the imaging desk, where they checked me in and then sent me back to my original stop.
I had to check in again even though I had already done an online check-in. They sent me to a high-tech waiting room that has an electronic board that displays the names of providers who are in clinic that day.
I thought it was odd that my provider wasn’t on the board, but I’ve seen an electronic glitch or two in my career, so I didn’t give it much thought. I realized when I was taken back to the care area that they were going to take my vital signs in a centralized vital station that was right across from the checkout desk and also adjacent to the door. Everyone can see what is going on with everyone else.
Many of us Midwesterners dress in layers because of snow. I was glad that I was wearing a short-sleeved T-shirt under my sweater instead of a long-sleeved version. Otherwise, I guess I would have been wrestling half my body out of my shirt for all the world to see. At no point did the medical assistant ask if I had a suitable garment underneath before asking me to expose my arm, which would have been considerate from a patient experience standpoint.
Medication reconciliation was performed in the open in front of two other patients. That is a patient dissatisfier in my book.
I was taken back to an exam room. I was told to gown up and that “the physician assistant will be right in.” I asked if they had the right provider on the chart since I was scheduled to see a nurse practitioner who I had seen previously. They told me that she wasn’t there that day.
You can bet that as soon as the assistant stepped out, I checked the patient portal. Sure enough, the appointment was still listed as being with the nurse practitioner.
When the physician assistant arrived, she didn’t mention the scheduling change. She seemed surprised to hear that I was scheduled to see someone else. Knowing what I know about electronic health records, this shouldn’t have been a mystery to anyone, because schedules don’t just spontaneously morph. Regardless, with a day off work and a long commute to the center, we forged ahead.
Afterward, I was told to go to a check-out desk, where no one was present. I could see through a pass-through to the other side, where a staffer had her back to me. She didn’t acknowledge me when she finished with her patient. I walked through, only to find three people in a line that I couldn’t see from where I was told to wait.
I didn’t know if they were ahead of me or behind me in line, so I headed to the back. That side of the office was a mirror-image layout of where my intake occurred. Everyone could see and hear everyone else’s business as patients were brought in, had vitals taken and medication reconciliation performed, and were checked out.
One bright spot in the visit was that while I was waiting, one of the medical assistants walking by said, “Is that you Dr. J?” She turned out to be a former member of my team from the urgent care trenches. I enjoyed seeing the photos of her children that she had on the back of her badge and catching up while I waited.
Ultimately I made it to the check-out desk. The staffer was hidden behind dual monitors with no ability to make eye contact with the patient. She proceeded to schedule follow-up appointments without confirming whether or not they worked for my schedule. I suppose they assume everyone just drops everything for an appointment at that esteemed institution.
She also let me know that they were in the process of implementing “ticket scheduling” via the EHR. She said that I would receive a notice to schedule follow-up imaging, but advised me to ignore it because it would be automatically scheduled as a linked visit with my next provider appointment.
My read on that is that the EHR team doesn’t quite have everything as buttoned up as it needs to be. Or, whoever designed the scheduling protocol doesn’t understand that some clinics have linked imaging needs that aren’t suitable for patient self-scheduling.
I have multiple EHR certifications, I am knowledgeable about ticket scheduling, and I understood the context of being told to ignore the notice. Otherwise, I likely would have been confused to see the scheduling request in my patient portal, which I checked in the elevator to confirm the dates for the follow up.
Another bright spot occurred as I logged in. A popup asked me to set a communication preference about seeing my results before they are reviewed by the care team. I hadn’t seen that before, and it’s a great patient experience feature.
From there, I was off to the parking garage. One of the two exit gates was malfunctioning, causing dangerous reverse maneuvers and a total traffic jam that was preventing anyone from exiting their spaces.The clinic that I was in sees up to 100 patients a day, each floor has multiple clinics, and the building has multiple floors. I’m thinking that the parking situation might be a little undersized.
After driving home in a general state of frustration, I was glad to see a notification that my visit note was ready for review. Although I’m an avid reader and enjoy a good work of fiction, I don’t enjoy it when that fiction is masquerading as a medical record note. The list of errors included:
- It listed an additional genetic mutation that I do not carry.
- It instructed me to continue the medications that were supposed to have been inactivated during medication reconciliation.
- Incorrect ages in the family history had been altered from what I entered during online check-in.
- It documented history taking that wasn’t done.
- A “comprehensive review of systems” was documented as negative, but they hadn’t asked me any review of systems questions.
- It contained fictitious exam elements, including head, eye, ears, nose, throat, neck, extremity, and neurological findings.
- It documented counseling that did not occur.
- It listed shared decision-making that didn’t happen, which was based on the alleged counseling.
- It documentation of answering my questions when I hadn’t asked any.
A note in the chart said that the contents of the visit were dictated using voice recognition software, but didn’t include any indication of AI usage. Actually, an ambient documentation solution might have yielded a better result since it probably wouldn’t hallucinate as many elements as the provider did.
It is possible that I have entered my curmudgeon era, but I simply don’t believe that this kind of provider behavior is appropriate. I also don’t think that patients deserve to be treated this way. When I hear people say that the US has the best healthcare system, I always think of situations like this and it makes my blood boil. What’s worse is that these things didn’t happen at a rural or underserved facility, but at a major academic medical center that has a top reputation.
While I was in the patient portal, I saw a message for a relative for whom I’m a proxy. It recommended that she have a mammogram despite being 97 years old and having had a mastectomy. I was happy to clear it out before she saw it, because she would have been incensed. Given the configurability of EHRs and individualization of care gaps, we shouldn’t be seeing things like that. Given that day’s experience, it was just one more layer of icing on the proverbial cake.
I know that healthcare providers are constantly being asked to do more with less. I live that situation on the regular. Plenty of corners can be cut when people are just trying to get through the day, but I draw the line at putting fraudulent documentation in a patient chart, or doing a bait-and-switch with providers who serve a vulnerable patient population.
I’ll be sending excerpts of this write-up to the powers that be, but I’m not at all confident that they will care.
Do you see these kinds of occurrences at your institution? If so, what are the solutions? Leave a comment or email me.
Email Dr. Jayne.
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