Wednesday, September 8, 2010

Things that make me grumpy

B12

Sounds simple, huh?

1 letter, 2 numbers. One of the B vitamins. It's important in a number of body functions, particularly the nervous system and blood cell production. It's in pretty much all meats and vegetables, and multivitamins you can buy.

To me, it's also a good example of what's wrong in health care.

Let's take Mrs. Olde.

She goes to her internist, and is complaining of feeling weak and tired. So he checks a B12 level, thyroid labs, and other stuff.

A week later, she's out with some friends, and trips in a movie theater. She breaks her leg, and lands in ER. She gets admitted to the hospital.

There she mentions that she feels weak and tired to the admitting hospitalist. So, with the usual pre-surgical labs, she checks a B12 level, thyroid labs, and other stuff.

She does fine in surgery, but afterwards has a mild anemia, which doesn't improve. So after she gets out of the hospital she goes to a hematologist. This doctor doesn't have any of the previous tests, and so orders another B12 as part of the work-up.

While she's recovering, she's taking Percocet for her broken leg. She mentions to her daughter that her memory is foggy, and so the daughter takes her to see a neurologist.

The patient comes to the neurologist. He thinks the problem is due to Percocet, but to cover himself he orders a head CT. Since he doesn't have access to her hospital records, and she doesn't have any of her previous labs with her, he orders a bunch of blood work, including a B12, thyroid labs, and other stuff.

Story over.

Now, a B12 level, according to Local Lab, costs $198. So this lady has had 4 done, for a total of $792, in less than a month. B12 levels generally don't change that dramatically in a month, so only 1 was really needed (yes, I know some of you are thinking a methylmalonic acid level is more useful than a B12, and I agree with you. But that's not the point here. And try getting Medicare to pay for an outpatient methylmalonic acid).

$198 isn't that much, is it? But multiply it by thousands of patients a month with similar stories. That's a HUGE amount of money wasted. And then extrapolate it to many other redundants tests: CBC's, TSH, chest X-rays. And then add pricier items (though not as commonly reduplicated) like CT's and MRI's.

I generally don't order labs if I know a patient has recently had them. I try to get the old records, then order anything I need that hasn't already been done. But many docs don't do that. And sometimes the patients are less than helpful. They forgot they had stuff done 2 weeks ago. Or don't remember the name of the doctor/hospital who did them, making it impossible for me to track them down (you'd be amazed how many times people have no idea what hospital they were in recently, or what doctor ordered their tests).

I'm guilty of this myself. Yesterday I admitted a guy to the hospital, who told me his outpatient work-up hadn't included any labs. So I ordered a bunch. This morning I came into my office to find everything I had done last night was also done 3 days ago, and was sitting on my fax machine. According to the hospital labs, the total cost on these duplicated labs was $1278.

I don't think the patent did this intentionally. He'd either forgotten, or (and this is common, believe it or not) thought that the labs his internist ordered wouldn't be ones a neurologist would want, and therefore didn't count.

Redundant tests, I think, are a huge waste of money. I'm not sure what the answer is here.

Some would say we need to have ALL these records in a humungous database, searchable from anywhere, and protected by elaborate security checks. This would likely be the best answer, but I think all of us have huge concerns about the security and privacy issues involved.

Better communication between doctors would help. You have no idea how much I appreciate it when a referring doctor sends labs and test results in advance, or even with the patient. That way we all save time, money, and blood on further tests.

Another option is to put the patient in charge of their records. Some are good at this, bringing copies of labs going back to their childhood. But most don't. Giving them a memory stick or CD with past tests sounds good, but those things can be forgotten. Or lost. Or not work on a different type of computer.

I don't have an answer for this. I wish I did. A good solution on a large scale would likely save a huge amount of time, money, and aggravation for all of us.

71 comments:

Anonymous said...

Ask some medical librarians. They're the information specialists, and yet librarians are often the last people consulted for problems concerning the organization and retrieval of information in any field. I bet they've got ideas they're just dying to share, and who knows? Maybe they'll have merit. Try it.

Anonymous said...

Here is Australia we have a great system. GP's. (general practitioners). They are the first port of call for all patients (unless they go to the ED). The GP refers patients to the relevant specialists, and communicates the tests & results already done; then each specialist writes a letter to the GP - containing test results etc. So, as long as your Mrs Olde goes to one GP practice (ie doesn't dr shop), everyone is kept in the loop and the one B12 level that the GP did would have been communicated to everybody.

I'm not saying our health system is perfect (far from it), but I do like the role that GPs play.

*disclaimer - I am not a GP, just a humble senior medical student and consumer of health care :-P

Anonymous said...

I come from France, and there, the patient receives a copy of all his/her blood and other tests results, at home, by mail.
Then it is easy to take the results to the specialist or any other doctor you see.

stargirl65 said...

I like the idea of patients keeping track of everything as well except that many will NOT do so in this country. They are very passive about health care. Many come to me and don't even know the medicines they are taking. They expect me to keep track of everything. Example-my gyn gave me some pills last week. They were white. But I don't remember their name and I forgot to have them send anything to you. (Even if they did have it sent it could take a few weeks depending on the practice.)

Trying to get records from other facilities can be challenging. You call medical records, get put on hold, then they want a form signed by the patient, you fax it and records might appear in 2-4 weeks. This is if you can even find out where they went.

A central place would be nice. I am not sure why people are so worried about things.

SBG23 said...

I think if banks and credit card companies can keep a record of every "vendor" or merchant your card has conducted a transaction at, and the results of each transaction... healthcare ought to be able to do the same. every lab, imaging study, ..every "medical transaction should be recorded and acessible via that card/account number. The same processes should be in place for when it's lost or stolen. If healthcare worked like American Express...We'd all be better off. We'd even know if someone was trying to use our information inappropriately.
The security that banks use for EFT's and so forth is pretty good. And face it, while I understand there are consequences to personal health information being passed around to the aunauthorized.....what has more immediate consequences... someone cleaning out your life savings and checking acount, or someone finding out that you broke your arm in 1986?

Anonymous said...

I used to carry my most recent neuro reports and labs (in universal .pdf format) on a thumb drive attached to my keys. Every. single. time. someone would have needed to see the information, you know what I heard? "Oh, we couldn't possibly stick THAT into our computer - what if it had a virus?"

:: facepalm ::

(I'd stop being anonymous if I could remember my password... ah, Topamax)

Grumpy, M.D. said...

Anon- I'd be concerned about the virus issue, too.

My office computer is a gold mine of identity theft info- names, addresses, birthdays, social security numbers, medical info, etc. A virus that covertly began raiding the database and sending it to someone would be very serious.

It would be very easy for someone posing as a patient to come in and hand me a memory stick with their records on it. And while I'm looking at the records it quietly puts a bug on my machine.

So I don't put others memory sticks in my computer, either.

Doug DeJulio said...

Yeah, I'm glad that my local health care system (UPMC in Pittsburgh) had a decent *opt-in* online record system that patients can access. I can see individual tests, when they were ordered and by whom, and what the results were (and yes, I had B12 done within the last month), and there's an easy button to press to ask any doctor I've seen about any of it. I took a while to opt in to the system, but now I'm glad I did.

So far the security precautions seem adequate, too, as long as users protect their passwords -- the site automatically completely logs you out after a *very* short period of inactivity. I'd like to see the option of adding a certificate or a OTP key fob or something to the login, but it's not bad as such things go.

CrownedwithVictory said...

Around these parts, there aren't that many labs to send work to. So most of us have our labs sent to LabCorp. We should just "assign" labs to patients like we GPs, then all you would have to do (theoretically, of course) would just ask the patient where their primary lab was.

101Md said...

Take the principle of Facebook, strip out all social networking features, substitute the photos tab for "lab results" and "scans". The "notes" tab would be the various physicians' dictations. The "wall" would be a laymans summary of drs notes plus any medication or other instructions. The "basic info" screen would be med hist, drug allergies, etc. Allow doctors and hospitals to add patients but not vice versa. Allow drs and hospitals to see other care providers for each of their patients. Of course don't allow pts to see other pts. Pts can log in and view test results and "wall". No "news feed" or status updates.
Make sure security is impeccable.

??? Maybe someday this would be possible.

Doug DeJulio said...

On the "memory stick virus" issue, there's a solution to that. I know how to perform that solution on a Macintosh or on a Linux system -- I'm sure it can also be done on a Windows system, but don't have the expertise myself.

Basically, you'd have a very cheap and low-power computer that wasn't used for anything *but* reading those files. On a Mac, if you enable the "guest" account, the account doesn't have the rights to write to most of the system, and the guest account data (preferences, bookmarks, cookies, even files in the home directory) are all wiped *completely* every single time you log out and back in. Such a system would be extremely resistant to that sort of virus (*especially* if it was a Linux system with a non-x86 CPU, like ARM or something -- just like most plant viruses can't attack kittens well, most x86 Windows viruses can't attack ARM Linux well. Monoculture is dangerous, in biology or information technology!)

Heck, know an even simpler way to do it? If the records are *image* files, you could get a digital picture frame with a USB port, and just use that. Don't copy the files to the device, just view them, and every once in a while, scrub (ie. reformat, factory reset, whatever) the device anyway.

kamikasee said...

What about a central database that required the patient to log in and delegate access to their records. If it were properly built, you (as the doctor) could find the patient in the system and request access (similar to a Friend Request on Facebook), and they could say Yes or No, and even specify a time period when you access rights expire.

It would be slightly more complicated for hospitals and clinics (where multiple people should have access to the information), but you could probably put the hospital or clinic into the system as an entity (instead of the individual doctors), and then let the hospital manage internal access much the same way they do now.

I think the main barriers to ideas and systems like this are 1) risk aversion of institutions (read: tort liability) and 2) the difficulty in integrating such large systems with proper security mechanisms in place. There is always a tradeoff between security and usability, and the problem is compounded when you have thousands of health care workers whose main job is not to be an expert, security savvy computer user. Just look at the privacy problems facebook has.

Amy said...

We have the exact opposite problem in veterinary medicine, esp emergency medicine. People bring in their very sick pet and then don't want to do bloodwork because "it was just done last month at his yearly exam." Yes, but he was HEALTHY at that exam and he's SICK now. The bloodwork has probably changed. "But I don't want to pay twice for the same thing." It's not the same thing if your pet's health has changed! *sigh*

Walt said...

Grumpy, you should delete all those Social Security numbers out of your records. There is no reason for them to be used in medical records. Any insurance companies still using them need to receive a clear message from patients that this is unacceptable.

I refuse to give mine anymore. I suspect most docs collect them in case they need to send the bill to collections, not for any medical recordkeeping.

Mike said...

One of the many things that the modern VA is getting right is that it's been able to go so far with electronic records. Any of the doctors I see within the VA have access to all of my health records, test results, and notes. I have heard that their progress with electronic records has saved the VA system-wide billions of dollars simply by obviating the sort of redundant testing you mentioned here. I don't know how to balance HIPAA concerns with making electronic records available for review for independent practitioners. I know that locally the major medical center here (Strong Health @ the University of Rochester) has been working to make it's own records universally available to all practitioners within their system, but that's only a fraction of the doctors.


Walt - even pulling SSN from records won't end the concerns: I believe that most people's Medicare numbers are based on their SSN.

danielle said...

The problem with 'assigning' a lab is healthcare coverage - does each particular insurance cover that particular lab. A lot of our docs do have preferences...but then comes into the insurance issue as well as personal preference. If you live in an area with only 1 - 2 available, that would be a lot different.

Old MD Girl said...

I just discovered what my dentist's name was yesterday and I've been seeing him for 4 years.

Oops.

I actually think we ought to embed microchips with our health record in our skin. That way a simple scan would reveal the last set of test results. People can't be counted on to be responsible about their own medical records.

Amy -- Interesting point about how veterinary medicine differs. A cynical person might think you were arguing that people need to be more financially responsible for their own health care. ;-)

WarmSocks said...

I get copies of all my test results, and take a notebook of them with me to appointments. Not to be annoying, but to have the information if it's needed. It helps.

Last time I saw my doctor she checked old labs on her computer, didn't find what she wanted, and told me she had another test she wanted to order. I asked which one. She replied, and I was able to say that the test had already been done - then pulled out my notebook and handed her my copy of the results. $350 saved, and the results were instantaneous.

Patients really should take more responsibility for making sure doctors have the information they need.

Swami Dil said...

On my visit to a consultant referred to by my physician, I found they had direct access to my latest lab reports. In Canada, labs and other such agencies do not provide reports to the patient, only to the referring and authorised physicians. Being a centralised data base (I beleive it is on a provincial basis)there is hopefully less duplication. One can of course,obtain a copy of the records from one's physician, if required.

The Mother said...

It would be lovely if we could put the patient in charge of his own records. Heck, it would be great if we could put the patient in charge of his own HEALTH.

But we can't. Because they're too stupid, too nonchalant, too litigious, too careless. Mostly the latter, I think.

Yes, e-records were designed to help. But the real problem is that the patients relinquish the responsibility of their care to the big cloud.

Syrlinus said...

As a Canadian living in the US, I will say one thing: the lack of a computerized system at most places is annoying. Having to refill out forms, etc. is a challenge. In Ontario (my home province) they computerized their systems (they use a *nix OS and it's a closed system) and it's added a huge amount of efficiency to the environment.

When I lived there, if I went through what your patients did, a lot of those labs wouldn't have been redone because there would have been an indication that I had those sames labs done previously (results would still need a request and patient approval).

Anonymous said...

"I refuse to give mine anymore. I suspect most docs collect them in case they need to send the bill to collections, not for any medical recordkeeping."

And, unless you pay in full with cash at the time of the visit, I would refuse to accept you as a patient.

emmy said...

Dr. Grumpy I couldn't agree with you more. I hate having repeated tests. I will ask Dr. A to send the results to Dr.'s B,C and D so I don't have to repeat them. But of the eleven doctors that I see on a regular basis, only four will accept sharing results. My insurance company comes so close to having a good answer to this problem by offering a Personal Health Record with my policy. It is a web based database that houses all of my lab results, diagnosis' and medications. But it has some major drawbacks that keep it from being useful. The first is that it screens tests that I have and infers a diagnosis. So it will state that I have ovarian cancer when my oncologist orders a CA-125 and that my daughter has diabetes because her doctor orders an A1c as part of his check up for anorexia. I don't have ovarian cancer and my daughter doesn't have diabetes. Another problem is that it can take a lab several weeks to send my insurance company the lab results, so there is nothing current posted there. But the biggest problem I face is that my doctors won't consider looking at it even though it is meant to be a tool for them, and I have electronically given them permission to view the information. I just get a blank stare when I suggest they can get view the test results there. One even told me that test results differ from lab to lab. Kudos to the person who carries his records in a notebook. I'd love to know how he obtains those records. Some doctors are good about giving me a printout. But most aren't and if I want a copy from the hospital, I have to pay a private company they hire to store the records. Last time I requested them it cost me $350. I know, HIPPA states that it is supposed to be affordable, but doesn't define affordable. The company can charge whatever it wants.

Dan R. said...

Amy,

Grumpy extends credit to every patient that has insurance -- the insurance may not cover the procedure, deductibles, etc. As an office manager, if you didn't provide a social, you could pay the entire visit in cash, and we would refund after insurance paid us.

Kim said...

I want my medical records. All of them. I want all my test results, I want all my records, I think I should be able to have them. I can't get them. If I want test results, I have to make an appointment to go in and talk to the doctor, and pay another co-pay, if I want my records sent to a new doctor, I have to pay $30.00 just so they can be faxed over, and they won't give me my own records so I can just carry them to the new doctor, they insist they cannot be given to a patient. Annoys the crap out of me.

Abby said...

I once went in complaining of extreme bleeding (menstruation). I had just had a D&C and told the doctor I wasn't sexually active because I was in so much pain. She sent me to the hospital for a blood test which I thought would be to figure out what was wrong. Instead, I found out later, it was a blood pregnancy test! I was so angry! She had wasted my time and money on a test that was stupid. I knew I couldn't be pregnant, and she never was able to help me. I ended up going to a naturopath who helped me. I don't believe we should be in a database (for security and privacy issues), but I do believe that doctors should be more upfront with patients in explaining what was being ordered. I wouldn't have gone for the test if she had told me what it was for. I'm not saying that everyone should go against their doctor's ordered tests, but perhaps if doctors actually told their patients what they intended to order, the patients could pipe up once in awhile if a test sounded familiar.

And good grief people, get involved in your healthcare! We need to be demanding our lab results for our own file.

WarmSocks said...

@Abby: I always take a copy of the lab slip so I know exactly what tests were ordered. At labtestsonline.org you can learn about most tests. Or ask your doctor what the test will show, and what the anticipated treatment will be.

Anonymous said...

Virtually the first question to be answered in a woman with vaginal bleeding is is she pregnant. The patient cannot be trusted to give an accurate answer. The risk is too high if she is mistaken. The number of times I have had a positive pregnancy test on a woman who tells me there is absolutely no way she can pregnant(virgin, tubes tied, haven't had sex in 3 years, etc) is quite numerous.

Watercolor said...

Just TRY to get a copy of lab results. Sure, for $20. WTF??? Had my annual physical last week and totally forgot to ask them to fax my labs to my neuro and gyno. Drat. Usually they'll do that if I'm there. At least, if I ask my doc, he'll tell the staff to. Not sure what happens if I call in and ask them to. I suspect I'll get the $20 fee mailed to me. Cheaper than paying for labs again, though, I guess, lol. Why can't I have a copy of my own results?????

Anonymous said...

I work helpdesk for a hospital with an extensive EMR. Over the years I've moved to see mostly only doctors in this hospitals system. When my outside doc orders labs I have them drawn here and faxed to her so they are part of my complete record. I've also had my older outside sleep studies scanned and added to my chart (something that the clinic did for me as a patient)

As a chronically ill patient this is a godsend. I'm not sure what I would do if I ever left this job and didn’t have such easy access to my chart (thankfully the patient portal is becoming more robust with time)

I know this has saved me from repeated labs and radiology scans.

There is a drawback – its annoying to be a sick patient in an appointment and be asked computer questions.

Frantic Pharmacist said...

Gawd, I wish we could make the public understand what you have just so aptly illustrated. But the idea of shared electronic medical records
(and people actually using them) just isn't as sexy as 'death panels.'

Anonymous said...

Interesting, the thing about this story is that although the question of medical records is a great one, I wonder about the results of the B12 level : ) Recently I've been seeing a huge number of elderly patients come back with levels less than 400 which is still "within range" but is at a level associated with neurological conditions. So, wouldn't it be funny, if here this woman's B12 level was 250 and look at all the really expensive testing she's done for strokes/brain tumors etc, when a B12 series costs about $60 in treatment.

Amy said...

Maybe I'm biased, since I'm a software developer, but I'm all for the humongous database idea. The security/privacy issues are solveable, and it just blows me away that we don't have this yet, when it's such an obvious way to rein in wasteful health-care spending. (And by the way, my health insurance premiums just jumped another 20%. Same as they did last year...)

Brit said...

In Thailand they have a card, same size as a driver's license or a credit card that they have to show to go see a doctor. The card contains all their medical history, past labs, past doctor evaluations etc... It is protected in the same way that your credit card information is protected. The card is actually processed on a different computer that only reads and stores those cards. Nothing else. For anything else another computer hooked to the same monitor is used, and a simple switch is flipped to switch from computer to computer. Nothing goes in and nothing goes out. It's protected, no viruses and only a hardcore hacker that had that machine in front of him could access the information. I think Thailand's minister of health estimates that they save 14% of costs just by doing this and not needing all those administrative costs, extra tests, paper supplies.

I don't see why this couldn't work here in America. We all manage to hold on to our credit cards and driver's licences for the most part. Adding one more wouldn't be such a big deal. A loss would suck, but it'd be rare, and not much more of a big deal than a lost credit card. I'm sure security measures would be put in place against theft, same as with all our other important cards.

radioactive girl said...

Since I see so many specialists, I am extremely good about bringing copies of my labs, surgery reports, etc. with to every appointment. The problem is when I go to my rheumatologist, they make it EXTREMELY difficult, if not impossible for me to get my own medical records. The blood tests she orders are often repeated by other doctors simply because to wait for the copy I can eventually get would take literally months. It is frustrating and most of the time I feel like sending my bill for the repeat blood test to my rheumatologist's office since they are basically the cause of me needing the repeat test. I don't understand why they quote "privacy issues" when I try to get the copies and make the whole process so difficult. They are my records. Who are they private from? Me? That doesn't sound right!

Repeat tests are expensive for me as well as the insurance company and honestly, as much as I love my rheumatologist, I am considering finding a new one that doesn't make things so difficult. (Obviously this is not the only issue I am dealing with there although that might be reason enough I guess).

Bob in Tampa said...

How about using an embedded microchip similar to those used to recover lost pets. It would need more RAM and the individual's health data would have to be encoded. Only the individual and designated health care professionals would have access to the data.

Thomas said...

I'm glad I decided to see Medical College of Wisconsin doctors, they all use the same database and refer within the system.

The Clinton Health Care reform of the 90s suggested the large database idea and people freaked because the government would have access to that information.

Some sort of opt-in system might be useful, though.

Jules said...

I agree with you and the other folks above me that a subdermal chip is a great idea. Unfortunately, we live in a country populated by imbeciles and religious zealots who are too worried about "anchor babies" and "death panels" (mentioned above) and whether or not our president is a muslim to allow us to move forward and better ourselves.

Kyla said...

I'm reading the book Routine Miracles by Dr. Conrad Fischer and the section I was reading today addresses exactly this! I hope that EMR is a step in the right direction, and it would make sense that medical history could be contained on a personal card, just like banking information is. Keep it in your wallet and whoever is treating you can access the medical information they need to treat you.

outre said...

agard! multiple b12 levels. :X

I brought my binder of records(which also exist as a digital copy) to my pcp when I switched and he said "This is great! He promptly handed it over to his office manager so the contents could be scanned and stored in the EMR.

Most of my specialists encourage patient record keeping, likely due to the patients being the rare chronic disorder group. Once one of my doc's NP handed me a binder with dividers at my visit to keep my stuff. Of course, that was after I switched to a bigger binder and the 1 inch binder wasn't gonna be enough... but I thought it was good idea to prompt people to start their own record keeping. One of mine frequently tells me to request copies of scans on a CD as a physician request, which results in no charge to me. I'd still request it even if I had to pay the $10, 15 fee required, but I do as told. (And... sometimes those scans aren't up on the server by the time I head to my follow up right after a scan, so CD actually is needed)

@Bob in Tempa: I once read a research study that seem to claim the pets with microchips developed sarcomas around the area where the microchip was implanted. Also the company that's the major producer of the microchips(forget their name) has weird ties that made the true goal of 'easy medical access' sketchy... details are lost in my mind atm.

All the microchip, CD and memory stick idea only works in the event the hospital/doctor you visit are willing to use them. Some aren't... and there are providers out there that are absolutely adamantly against EMR...so in theory, fantastic but in practice, not so much, not yet.

In the end, I'm in the mindset, it's your body, take some bloody responsibility to knowing what's going on... sheesh.

Dude'sDoctorMom said...

Agreed 100%, Dr. Grumpy - but even *within* institutions, the same thing happens. I practice geriatrics, and inherit many patients post discharge. In reviewing their hospital charts, I can't tell you how many daily B12s, TSH tests, I've seen, daily INRs for days and days at a time, and others that I think the hospital lab should just outright ban, without authorization from a some higher power.

It's a teaching hospital, so that's part of it, but I teach the "intro to clerkship" course and I drill it into their heads to look back, but it's NOT WORKING.

Of course, this same lab paged me out of clinic with a "stat" HbA1C and folate, (that I didn't order), so I'm probably expecting too much...

Ladyk73 said...

The biggest issue I see....is patient's access to their own records!!!!! I actually had a psychiatrist request that my primary do some tests (metabolic stuff impacting mental health). My Doc is great, I got an appointment, got the tests, he gave me the paperwork results and I hand delivered them....
But getting info as a patient can be horrible. Same doc gave me an mri for my spondylothesis. The nurse called me and told me some vague response and told me to continue PT. She seemed upset that I asked her to give me more details... I seriously had to ask her to just read me the results. I wanted to know what grade it was....

Ladyk73 said...

I would have been MORE aggrevated if this test was repeated and was NOT normal, and no one got the results and/or did nothing about it

Anonymous said...

Google has been trying to do exactly this for quite some time. The privacy issue is HUGE, esp given Google's track record in this regard, but the site is: http://www.google.com/intl/en-US/health/about/. It links to AllScripts which is one of the big players in e-prescribing/outpatient mgr systems out there. I took a look and the Cleveland Clinic system one of the other commenters posted on links too...they may actually be using Google for this purpose...I don't know.

The waste out there is JAW-DROPPING. It is CRITICAL to getting costs down. Do you know the number of times a pt comes in with a lisinopril rx from a gp and is already on quinapril from the Cardiologist or vice versa. It can make you want to pull your hair out..all classes of meds/all specialties/all the time. Psych meds suck the most...sometimes you have to duplicate/keep throwing spaghetti at the wall until something sticks. BUT when I have a pt with an rx from Lexapro from MD A and Effexor XR from MD B...who knows? I know you're annoyed...I'm annoyed, but I have to check. YES, Dr PIA...I know they are used together in some cases, but...uh-huh...I know you are busy. I am too. Could you please just give me an answer so that we can get on with our day? You can't blame the pt - how would they know? You can't blame the MD's - the patient probably didn't mention it or described it as "the blue pill...for my blood pressure, I think". It's a terrible situation that can and has had dire consequences for patients and their providers.

RP said...

I have worked with an pulm MD for yrs., that does the CYA thing. Every frickin test in the book ordered whether needed or not. As an ICU nurse I cringe (literally) every time I see him come in. I know there will be at least 1.5-3pages of orders for me to go thru.
:-(

ERP said...

Check out this place. All the MD's work together in this sprawling system and all info is shared. Saves TONS of money and prevents this kind of thing you talk about.

http://www.geisinger.org/index.htm

Anonymous said...

Our local lab will mail you your test results for free provided that you ask for them & sign a consent form at the time of the blood draw. They don't offer this information to you, I found out from one of our patients.

Felix Kasza said...

@Kim, @Watercolor:

Of course you can get a copy of your results. In my experience, if you ask for it at the time of your blood draw, they'll gladly mail you a copy -- and since they won't have to dig up anything that was last week and thousands of patients ago, the lab or doctor usually won't even charge you.

Cheers,
Felix.

Felix Kasza said...

@Amy:

I'm a dev, too. Actually, I am a developer working on security software -- crypto, access control, identification, all that stuff. And _I_ am not going to hand my data to a government or anybody else of that kind.

My insurance already collects way too much stuff for my taste, and when I look around and see that neither the government nor companies are able to protect my SSN or my credit card number, I fail to see how a centralised database of the most private information ever could be anything by a complete and unmitigated disaster.

Or would you like every hospital employee in the state to find out whether you ever had an abotion, a discreditable disease, or worse? Would you like insurers and ERISA employers bribing your doctor's receptionist to find out how expensive you'll be if they insure you?

And no, I am not a pessimist. If I learned anything in this field, it's that I am still too much the optimist. :-(

Cheers,
Felix.

middle child said...

Best thing is to have everything run through your G.P. And if you are unable to remember things, either write them down or have an advocate attend appts. with you. If I am due for my annual bloodwork, my G.P. always checks the records and if there are any recent tests, then He only does the remaining ones that are neccesary.

The Bus Driver said...

place a microchip into their hand. Every time they go to the doctor, scan the microchip number, then the doc has access to all the records of that chip number.

Rubychopsticks said...

This seems like something I may need to refer to during at least one of my multiple med school interviews coming up. But back on topic, I agree...our healthcare system needs some serious work. It would benefit almost everyone, except for maybe insurance companies. I think we should just get rid of them...lol

Amy said...

Inland Northwest Health Services (INHS) has a fantastic model in Washington State! A handful of hospitals and health providers got together to share electronic medical records, so a neurologist who participates in one group can see the labs ordered by a doctor at a different hospital. Cool stuff. HIPAA approved and all.

Anonymous said...

Re: credit card sized record.
Parents can't even remember to bring vaccine cards to their kids' check ups.
I can't recall how many times I've heard "if you think he needs it, just give it to him. "

Anonymous said...

Amy the vet (re: repeat labs on sick animals)..

...This just shows the major divide between human and vet medicine, as in the latter the costs aren't magnified and hidden in a third party carrier package. Trust me, if Mrs. Olde or her family had to pay out of pocket for these four sets of labs, they would have found a way to communicate the first set to other docs. I am sure Mrs. Olde is much more frugal with the health care of her aging Yorkie, "Sweetums".

When dinosaurs roamed the earth and people directly paid their medical bills, they knew what stuff cost and likely valued the care at a psychological level as well.

Pattie, RN

Megan said...

I second Amy's post re: vet med... Our clients, for better or worse, know the cost for each test we run and so are more likely to remember that we've run them (although still not always- clients will tell me their pet has "never had bloodwork" and then medical records from their primary vet show CBC/Chem/UA results from a month or two ago, or they'll tell me a "biopsy" of a mass was performed when the pet actually had a heartworm test done or something). It is exhausting having to explain the rationale for running every test we want to run, but at the same time I think having to justify our diagnostics to clients keeps us from running tests that aren't really necessary.

Don said...

Rotten deal about this whole thing is that there is already a central database of everyone's medical records.

Well pretty close. There is a company called the Medical Information Bureau. Health Insurance Companies use it like a credit reporting agency.

They submit information about what services you use, how much they paid etc. If you apply for health insurance from a different company and they check with MIB and find out you weren't honest about your medical history, you can be turned down for coverage or have claims disallowed.

There maybe some scaling problems, but if MIB already has a medical history clearinghouse, it would seem fairly reasonable that they could do some enhancements and become a central records clearinghouse for hospitals and doctors, not just insurance companies.

I think that HIPAA is a stumbling block to a true central records system for the whole country. No one is willing to build a system because the liability if someone should accidently access the wrong records would be huge.

Anonymous said...

A couple of distinct thoughts:

1: Given the current settup it seems that the quickest way to set this up is through the insurance companies. They are already paying the bills and are trusted (like it or not) with our sensitive medical data.
Would not take much for them to track lab results in s a doctor friendly format.

2: The base security issue should not be keeping your SSN secret. The system must be fixed so that simply possesion of one broadly required number does not allow identity theft.
If banks and other institution were required to physicaly verify ID (picture + signature etc) before granting credit most of the identity theft issues would instantly vanish.

Anonymous said...

I love the "smart card" idea, but it's already been attempted by a start-up in my town that tried to develop one across insurers. The problem is that each mega insurance company has to play along, allowing access to their record-keeping systems, personnel and customer base. Every insurer has a completely different system. One major company got greedy and halted development, figuring it could someday create its own branded card and reader. And of course, years later, the start-up's out of business and nothing's been created.

Anonymous said...

"Every insurer has a completely different system."

And that's where so many of the problems come from, isn't it?
We can definitely try to learn from other countries, but so much is not applicable here because of:
1. the enormous mess caused by competing insurance companies; and 2. privacy regulations such as HIPPA.

Olivia said...

I wonder if you could work out a system like Grumpy's been writing about regarding prescription meds?
That is, a doctor could pull up records on what tests have been run within the past year or so...and find out who ordered them, if not results directly. Granted, this means results might have to be tracked down to the doctor who ordered them, but it would avoid privacy concerns.
Didn't Microsoft spearhead some gigantic effort to create a medical records system? There was a big fuss (including privacy issues) when it first made news....wonder if they dropped it.

Dr Jr said...

I was told a while back a that a CRP test costs £60 each.

I'm not even going to think about how much money is wasted on repeat CRP tests.

emmy said...

@Felix Kasza - I would really like to know how you find it so easy to get all of your medical records. If you could write down step by step instructions, it would probably sell like wildfire. My experience goes something like this: In the doctors office. The doctor comes in decides on a test. I go to the lab and have the test drawn. I ask the nurse and the lab assitant to please send me a copy of the results. They tell me they aren't allowed to send it until after the doctor reviews it. Several days later, the nurse (if I'm lucky) calls and says "your triglycerides were a little high, continue taking your medications and get a little more exercise." I say "can I get the actual results" I hear a pause, like she can't believe I would want to know and then she quickly reads me the results. Then I say "no, I mean can you send them to me because I'd like to have them available for my other doctors." Then she says, "oh, we'll send a report to Dr. A." "Fine but I'd like a copy" Then I'm told to send a fax requesting the records and I may or may not ever actually get the results. Hospitals are much worse, because you can't ask for a copy each time a test is done or a result is recorded. If you ask for a copy of the report you are referred to an outside company who charges a huge amount of money for your records. Technically it's illegal for them to do it, but HIPPA failed to define what a reasonable cost is. So they can charge whatever they want.

Felix Kasza said...

@Emmy: "I would really like to know how you find it so easy to get all of your medical records."

I am sorry you have so much hassle getting your labs and other test results. For me, it's easy. My insurance covers pretty much everything at 100%, no copay, no deductible, no coinsurance, and no referrals or pre-auth required, either. But I still choose to see an internist as "my" doctor, and he is kind enough to coordinate my care. So when I do go see a specialist (I am diabetic and a repeat customer for orthopaedic surgery), it's with a little note from my GP, and I also expressly ask that my GP be kept up to date on everything.

For routine bloodwork, that happens in my internist's practice anyway: Standard stuff like HbA1c is done right there, others are sent out.

In all cases, the results get added to my chart at my internist's -- and the chart has a sticker saying "mail copies of all labs and tests to patient". And that is all it takes. If your GP is not willing to make that effort, I would consider whether he or she is really so good that it is worth the hassle of having to fight for labs.

In hospitals, I found it easiest to approach a nurse at the nurse's station, in the middle of the night, when it's least busy, and ask for a printed copy of my chart -- after making sure that the hospitalist on duty or my attending doctor doesn't mind. Worst case, I get the data a week later from my internist.

Again, I am sorry for all the annoyances you are experiencing. It shouldn't be that way.

Felix Kasza.

Kat's Kats said...

All of the docs associated with Vanderbilt (two of my specialists are there two or is it three? of my husbands) are integrated into their system. They do a proper med history when you come in to see if anything has changed.

My pcp is a family practitioner who has know me for ages. Any time I see a new specialist I immediately sign a paper requesting that they send any and all information from their office to her. I check with her periodically to make sure she's getting it and then call whoever isn't whatfor. ::narrows eyes::

Frankly, I'd love a safe way to electronically connect all of the doctors, pharmacists etc. Think about how many lives could be saved.

stsymo - smart system most (needed)

quixote said...

I think we need to start identifying ourselves by country. Felix, for instance, finds it easy to get records and talks about a "GP." So he's probably in Britain or Australia or some civilized country.

My experience is much more like Emmy's. And I'd be willing to bet she, like me, is in the US. HIPAA and legal CYA and insurers and paranoia have well and truly stuffed up our system.

I've thought a complete centralized database could be an answer, but security professionals, like Felix, always seem to feel it's a terrible idea. And they ought to know.

So how to protect privacy *and* compensate for the desire to forget about all that icky medical stuff as fast as possible? Maybe some kind of centralized database where records can only be accessed if the patient is one of those providing a multifactor key? I realize anything central can be hacked. But anything not central can be forgotten. An enigma wrapped in a dilemma.

Felix Kasza said...

@Quixote: Good point. But as I have been living and working in the US (Pac NW) since mid-2004, I am starting to think that I perhaps was just lucky in my choice of GPs. (I call them "GPs" because my school taught British English -- I grew up in Austria and later worked with Britishers, too.)

I would *love* a centralised database, but the problem is one of trust, leaving aside bugs that lead to vulnerabilities.

If I could, every time that someone wishes to see or alter an entry in "my" part of the database, check: who this is; why the access happens; and what is being looked at; then I could approve or not, as the case may be. But it starts with the "who": Unless the person is known to me and sitting right next to me, it is actually quite difficult to prove identity. Usually we just accept proxies like "if you know Felix's password, we'll say you are he" or "if you have Felix's smartcard, we'll consider that proof of you being Felix". You think a health care worker might stay logged in if he just needs to run to the bathroom?

Worse yet: With insurance billing and such, thousands of people need access to your health records; at the very least, an insurance will check that Dr. X, who claimed to have done Y to you, didn't charge more than $Z. So your insurance company now knows that you got treated for a social disease -- but, at least it stays with your insurance company instead of being accessible state-wide.

Anyway, all that has already happened. Remember when a couple or three hospitals fired employees for accessing the admittance records of some B-list celebrity or other? If it's impossible to control a few hundred employees with a clear data access policy and in one location -- imagine the problems if you scale this up by a factor of 100,000.

The only option that I see is one that was mentioned in this thread: I carry my own data around (card, USB stick, chip under my skin -- but a physical object that, like a smartcard, should be unique and should be keyed only to me). I delegate access for certain parts to certain people, with certain restrictions. Examples:

- Allow reading and changing and adding to Dr. X
- Allow Dr. X to delegate his permissions to all persons who are employees of his practice
- Allow Dr. X to allow reading to my insurance carrier, but only information that was added by his practice
- Allow all access to any EMT and any doctor after they identify themselves to my chip, certifying an emergent condition
- Allow EMTs and doctors to delegate access ...

and so on. The problems are obvious: Unless it works as simply and intuitively as the lock on your door, it's not going to get used. Then: Who are my doctor's employees? What assurance do I have that his employee list is secure from tampering, not to mention that is must be kept up to date when employees leave? How can I be assured that all accesses are logged and reported to me if I cannot verify that the program at hospital A is a fully secure and compliant implementation? And if I do get those reports, how can I tell legitimate accesses from illicit ones without (a) having a degree in CompSci and (b) wading through a hundred pages of log entries per month?

I deal with this stuff daily, so I know it. I don't expect my sister, whose specialty is something different, to know the ins and outs -- but she, like you, knows that it may be harder than it looks at first glance. What I find unforgivable are politicians who use my taxes to pay their cronies as "subject matter experts" and who still are either ignorant of these problems, or who are willfully hiding them.

Cheers,
Felix.

Anonymous said...

When my neurologist & my internist ordered 4 of the same labs, I asked the lab if they could just do one set of the 4 labs and just fwd a copy of the labs to the other doc. They said they could. Later, I got my bill and my results. They didn't. They reran the everything and double billed me. =( And I still paid. =(

Sometimes even when the pt tries, the system just won't work with them

Anonymous said...

As mentioned: Ontario. A single-payer system like the Canadian one solves this, and many other problems. The US could do it better.

Considering that my insurance company ends up knowing enough to call my pharmacist and tell him not to dispense my refill until I'm nearly out of meds, in spite, for pity's sake of the fact that my insurance doesn't actually cover my meds, I am sure it'd be far from difficult to actually keep track of people's tests with a centralized system.

I used to work for a vet and never heard of any animal developing a problem with the chips. They are ceramic-coated. Sarcomas around them sounds like an urban legend, or a confusion (certain formulations of rabies vaccine are associated with sarcomas around the injection site, in cats). The chips do not have RAM and record only a number. The data is associated with that number in a computer system. Leading to the amusing yet tragic problem of finding lost animals that have chips with numbers that aren't associated with anything because the vet or owner never sent in the paperwork.

I was, as a vet tech, and am now as a reader of these comments, shocked at how many people think microchipping human beings is a good idea. It makes me think of certain yellow stars and blue tattoos. It is also amazing because when people describe potential uses for chips in humans and even the placement of the damn thing (medical records, financial records, put it in the hand) they never seem to notice that their proposal fits the description of 'The Mark of the Beast' in the Bible. I'm an atheist, but I still don't think the mark of the beast is cool. Sheesh, people.

The Ole' Apothecary said...

Do the dateabase!! So, hey, I'll give up a little privacy.

I know this is a huge public confession, but my serum creatinine is 1.

I hope my friends and family will forgive me.

Loren Pechtel said...

There's a perfectly safe way to handle reading the PDFs. You have a machine for the purpose and it's running something like DeepFreeze. Don't worry about viruses, when you're done reading the file you simply reboot the computer. Everything gets reset so any malware is gone.

I do agree with the idea of keeping copies of your labs although I handle it a bit differently--they all go on a spreadsheet. It's a lot more concise and makes it easy to view any changes over time.

 
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