The Problem with Patient Based Portals and Mobile Healthcare Today

I was recently asked by a large New York City based consulting firm regarding my thoughts about mobile healthcare and where I see things headed.

I gave them my two cents, but thought to share with my readers.

As any patient who has been through the healthcare mill knows, there is a profound lack of communication among private offices, hospitals, and health systems.

Let's start with a true story...

I recently saw a patient in the hospital who was admitted through the emergency room with severe sinusitis who had been on multiple different antibiotics without relief and even had surgery 1 week ago after which she was hospitalized for a few days for unclear reasons. She also had multiple drug allergies. Problem is, she didn't know much of what was done to her, what her allergies were, and most importantly, received all her care in a different hospital system. It was also the weekend. 

I couldn't really start treatment on this patient until I knew what was done as I didn't want to waste healthcare dollars on treatments already tried and failed as well as repeat CT scans that were already done as well. In terms of life and death, I couldn't really start any medications until I knew exactly what her drug allergies were. 

I called the other health system's medical records... closed for the weekend. 

I called the ENT on-call at the other health system who did not know anything regarding the patient. 

Ultimately, I was able to get the information I required by a back-end route... The patient knew cultures were obtained during surgery. I also had a friend in my hospital microbiology department. I contacted my friend who fortunately knew the microbiologist at the other health system who than looked up the information we needed and faxed them over to me.

If I did not have any personal contacts, I would not have been able to do anything until Monday.

Would a patient portal have helped me out here? Perhaps...

Would mobile healthcare have helped me? Doubtful if a non-functional patient portal system was in place.

The Problem With Patient Portals

It's all fine and dandy if a patient sees ALL their physicians within the same health system like Kaiser Permanente or Duke Medical Center. Mobile health makes perfect sense. Patient portal can access all a patient's records.

Problem is when you get beyond a large health system and where the majority of healthcare occurs which is in community settings.

For example in my community, there is no single large health system.

There are private practices and the hospital. We all use different electronic medical records. The electronic medical records (EMR) do not communicate with each other.

As such, if a patient portal is used, we ALL would have to use different patient portals which can only access information from that one practice and none of the others.

So for a given family, they may see the pediatrician that uses EMR #1. Father see primary care doctor using EMR#2. Mother sees OB/GYN that uses EMR#3. Mother also sprained ankle so also sees an orthopedic surgeon who uses EMR#4. One of the kids also sees ENT for recurrent ear infections who uses EMR#5.

Each of these EMRs do not communicate with each other. As such, even if all of the practices uses a patient portal, they all would require the parents to remember each practices'  different portal web addresses which each require different userids and passwords. Though I'm sure there will be some people who will do exactly that, most will not or won't remember the web information.

As it is right now, I have a hard enough time remembering my current collection of userids and passwords for my bank, Amazon.com, gmail, insurance, etc.

Not sure I will use a patient web portal which I may even think of accessing no more than once or twice a year if I'm basically healthy.

The Problem with Mobile Healthcare

How in the world will mobile healthcare work anywhere except in big medical centers if electronic medical records are fragmented out in the community like it is now? After all, mobile healthcare is basically being able to access medical records quickly and easily from a smartphone rather than a desktop computer.

But if you can't even achieve that task with a desktop computer, how can a smartphone???

It's like trying to build a house with a weak foundation.

In order for patient portals as well as mobile healthcare to REALLY work, communication needs to exist between different electronic medical records regardless of the vendor.

The Solution

For patient portals and mobile healthcare to really work and be used, we first need to treat electronic medical records like the computers they reside on. There currently are many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

Once inter-operability and communication standards exist for EMR systems, only THAN will mobile healthcare and patient portals be the disruptive concept that is being prematurely attributed to these systems right now.

The golden goose being a patient (or physician) will only needing to access ONE patient portal that can access medical records wherever they may reside.

Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

HIPAA Allows for Regular Email Communication Between Patients and Physicians

There is a widespread mistaken belief that HIPAA prohibits physicians from communicating with patients using regular un-encrypted email as well as with other physicians about patient care.

HIPAA, for those who don't know, is a law that requires patient information to be kept private with safeguards. Email (such as yahoo, gmail, aol, etc) is not considered a secure form of communication.

However, HIPAA does allow for such un-secured email communication under certain circumstances. I quote from the horse's mouth:

"Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications."

As such, it may be worthwhile for a patient to acknowledge the following statements before an email can be sent from a practice website using un-secured email:

"I understand email is not considered secure and as such, is not considered a confidential method of communication."  

"By your sending an email to us, you are giving permission for us to reply by email."

Even if private health information may be included, that's fine if, I quote from the horse's mouth:

"Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail."

Read more about un-secured email communication as it relates to HIPAA here from the Department of Health & Human Services.