Sunday, July 02, 2006

Introspection

I can't begin to count how many times this has happened to me. I go to a delivery and while waiting for the baby to deliver try to find some history on the mother and fill out our delivery room consult form. Besides looking for basic things like the mother's age and number of pregnancies, we also want to know some of her lab results, such as blood type and tests for hepatitis, syphilis, and HIV status. However, in this case I can find practically nothing about the mother. Why? It's not because the mother didn't have them done; it's because the obstetrician's office didn't communicate the results to the hospital.

Women who have prenatal care have these tests usually done in early or mid pregnancy. Obstetricians, whether at our clinic or in private practice, are supposed to send these results to the Labor and Delivery area of our hospital when the mother is about 34 weeks along, so we will have them when the mother comes in to deliver. This is a common arrangement, but at our hospital obstetricians only do this in about 60% of pregnancies. For some obstetricians the percentage is much lower. There is no good reason why some of them don't send them in; rather, it usually occurs because of laziness or inefficiency on the part of the obstetrician or his or her staff. When the results have not been forwarded to the hospital, the labs are drawn again when the woman is admitted in labor. Tests, sometimes expensive ones, are repeated. It might not seem like a large amount of money per patient, but when you multiply the cost per patient by several hundred - the number of times per year we need to duplicate tests unnecessarily - it adds up to a significant chunk of change.

I write this post in response to Dr. Rangel's request for ideas about what's wrong with the U.S healthcare system for this week's Grand Rounds. I'm sure there will be many fine posts about things like malpractice and tort reform, access issues, payor and insurance reform, or simply about getting rid of as many administrative layers as possible. But too often we doctors are unwilling to look at ourselves and at what we can do right now to improve healthcare. I'm not saying that improving the rate at which OB's send in their prenatal labs is a huge thing, but I bet that in every specialty other doctors could come up with similar examples of wasted or duplicate tests, wasted simply because we are unwilling to make our offices or clinics as efficient as they could be. There are other examples of waste due to our own laziness, too. I hear internists in our hospital complaining that they have to keep patients in the hospital an extra day because an X-ray result is not back yet. It's not back yet? Well, then go down to radiology and find the film and a radiologist to read it. And the lax job we physicians do in getting rid of bad doctors is a whole other topic.

There are lots of people we can blame for problems in healthcare, but physician friends, we have to fix our own problems before we can expect others to fix theirs. And by the way, although I recognize there are many problems with U.S. healthcare, I still think it's the best in the world.


P.S. A new Pediatric Grand Rounds is up.

9 Comments:

Blogger Jen said...

Reading your post made me think about how I can help improve the health care system as a consumer. I've certainly not paid enough into my insurance for what I've gotten out of it. I've been severely preeclamptic twice, and have two beautiful former preemie daughters. It feels like day in and day out I review insurance paper work to identify errors some to my advantage and some not.

As a consumer of health care, I need to do a better job of understanding the costs of what my family consumes. I think we Americans have become lazy. We rely on somebody else (aka insurance cos.) to do our jobs as consumers. I know that I'll be doing my small part to find the best quality health care while paying reasonable prices for it. I will not go blindly into the night anymore.

5:05 PM  
Blogger Dream Mom said...

Labs tests is just one area of huge inefficiency. Not only aren't tests forwarded, but sometimes a doctor may want to run tests at their own facility so they'll do them again. Some blood work takes a while to get back, like some of Dear Son's seizure levels, and I wonder sometimes, if they are ever even sent to the right facility once they are completed. I don't have any issues with the Big Academic Medical Center, it's mainly when tests are done in the ER elsewhere and then you wonder if they ever got forwarded.

And medical history, it's another one of my complaints, they ask me for it a gazillion times and yet, there are times when people (this includes attendings, residents, case managers, nurses, etc.) don't even bother to read it before entering Dear Son's room. Sometimes, I'll ask them to leave and read the notes, then we can talk.

Don't get me started, I've got a lot of thoughts on inefficiencies in the healthcare system and a lot of thoughts on technology that is supposed to help these issues as well.

I have to agree, that overall it's a good system, but there are many areas for improvement. Until we resolve some of the privacy issues and make certain that our data is really secure and that big brother and our employers don't have access to every detail of our health, we won't make the kind of changes we need to.

7:11 PM  
Blogger Flea said...

What?!

Doctors not communicating?!!! Que scandale!

Flea

5:24 AM  
Anonymous Shamhat said...

The patient could have a copy of their prenatal labs with her. That would help not only the case where the doctor hasn't sent them to the hospital yet, but also the case where the patient unexpectedly goes to the closest hospital rather than the one she planned to go to.

9:33 AM  
Anonymous L said...

I know a clerk who works in the radiology dept at a suburban hospital. She told me that if a patient calls up and requests a report, they will not mail or fax it to the patient. They will only fax it to a doctor's office.

However, she told me that if the clerk who gets the report request either forgets to fax it or loses the fax request, the report will never be sent. And no one will catch that it wasn't sent. And no one will be held accountable if it wasn't sent. And the office manager will have no idea of how often this happens. Beyond this inefficiency, this makes it more difficult for the patient to get appropriate care from their doctor, and for that doctor to do their job well.

On the subject of using more electronic technology to reduce inefficencies - the largest BC/BS insurer in my area has gone to all electronic referrals. You think this would make the system work more smoothly. Yet, I watched a clerk in my family doctor's office try and pull up one of my referrals on their computer, to see if it had been processed. First she had to get the username and password for the insurer's site. Then she had difficulty figuring out which referral was which, because at that time I was seeing two different specialists for unrelated conditions. The specialists' name weren't on the referrals, but their group practice name's, which I didn't know. The address of the practice offices weren't listed, but rather the practices' billing offices, some of which are located at other sites. Some of the specialists required that I get both a referral for their office, and a referral for the hospital that they practiced at, to add to the confusion. I even had two doctors who work at the same office, but who belong to different group practices, why I don't know.

It took the clerk and I four minutes to wade through all of this information. Not so efficient after all. Fortunately, now the insurer lets patients pull up their referral information on their own computers. Since I only have one case to manage (my own), the referral retrieval process works quite well. Perhaps this is what is needed, the ability of patients to have computer assess to their own records, since we are the most interested in what those records contains.

10:59 AM  
Anonymous Anonymous said...

Just wondering if you've seen this documentary:

http://www.littlemanthemovie.com/home.html

9:58 PM  
Blogger NeoNurseChic said...

Good for you for writing this! I have one very strong topic on my mind tonight as a problem in health care that I would love to write about, but I can't share right now due to confidentiality. But let's say it falls into the general topic of saving life without knowing your reasons for doing so, at all costs, no matter what the outcome. You've already debated this in some ways here, so I'm not going to get into it again.

I've had a lot of trouble getting my own records in the past, which sounds ridiculous. Back in 2004, I had 2 DVTs in my left arm. So once I was discharged, I went back to Penn State to finish my senior year and they wanted me to get a family doctor there who would get my PT/INR done weekly. Well, the family doctor I found wanted to know the detailed reasoning behind why I was on coumadin and needed all these tests. Afterall, he didn't know me. In order to get my records, I had to have my dad and a nurse back in Philadelphia forge my signature and medical records request form, then had to pay about $50 and wait another 4 weeks for my records - many of which were actually incorrect! I was appalled as I read that my own age and current medications were incorrectly documented. My friend claims this is because some poor neuro intern that didn't even know me had to write my transcription report, but that is not a good enough reason for me. That alone is why I was given pamelor while on parnate. For GOD'S sake....ACCURATE DOCUMENTATION!!! I sat with a highlighter and highlighted something on almost 50 pages of record that was an incorrect fact (IOW, not just my opinion). It was very disturbing... And besides, by the time they got it to me, the family doctor no longer needed the history as he'd had to be treating me for over a month.

Just today, a nurse sent off a vanco trough and an ABG on a 400+ gram infant. They were sent in the same tube. The lab ran the trough and said they never got the ABG. They were in the SAME tube. The nurse said she was going to have t o file an incident report but ultimately just really wanted to know what happened to the lab since they were sent together and every time we drew out 4cc of blood, we had to transfuse again. The lab supervisor got all in a huff and said that an incident report wouldn't solve anything...then she found the slip and said that the lab must've been accidentally thrown away...She actually said, "That happens sometimes." as if that made it okay!!! I would've personally requested the woman come up and look at the 400 gram infant we were then forced to draw a new lab out of.

And just a couple of weeks ago, I sent 2 green tubes for drug levels and a BMP. 2 hours later, I'm looking for the BMP and they say that the slip says, "Run BMP later." WHAT?! It was in for morning collection and I drew it myself because the baby had an IV in each foot. I didn't yell....yelling solves nothing but to make people more defensive. So I took a quick deep breath and explained that the BMP was definitely needed now. She then put the labs in as "add-on request by floor" which then required additional approval and orders (and...additional $$$) and then even reported the BMP with a ridiculously high K and a note that said, "Grossly hemolyzed." No kidding.... I didn't send it for it to sit for 2+ hours...and now I have to send it again to get an accurate K+...

But I digress... There are thousands of things that nurses also do that they need to look at. Daily I notice things that even I do and wonder why I'm doing it. As an entire profession, I find that the medical world very often slips into a comfort zone of procedures and protocols without stopping to ask why. I'm not saying I'm without blame - I do it, too! I know I'm a part of the problem, but I am always actively looking for ways to fix it to the best of my ability as a lowly staff RN!

Take care and sorry for my long rant!
Carrie :)

2:58 AM  
Blogger neonataldoc said...

Thanks for the ideas. Shamhat, that's a good suggestion to have mother bring the labs with her, but you would be surprised at how many fail to do so.

I think in some ways we have to be our own best advocate for our own health care. It's not so hard for people like us to do, because we have some knowledge of health care, but it can be pretty tough for people who are close to being functionally illiterate.

I haven't seen littleman the movie. Maybe I'll look it up sometime.

2:12 PM  
Blogger WendyLou said...

I wasted a second opinion because of this problem. I requested all my records of my pregnancy be sent to the second opinion doctor's hospital. I even called and followed up on this. The only record that my OB's office faxed was my record of a surgery I had done at the second opinions hospital, a record already there. A very frustrating vist.

3:51 PM  

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