New City, New Care = So Far, So Good

Well, establishing care in New York hasn’t been as easy as I’d hoped, but the care that I have received so far, other than at the student health center, has been pretty good.

I have student health insurance, so I have to get referrals from the student health center.  I went there, and was honestly less than impressed, but have basically set up a relationship so there is someone I  can e-mail there when I need a referral.  This means I do not need to make the trip to the student health center every time I need a referral, and I think this relationship works well for all parties involved.  I don’t think they really want to deal with my complicated situation, and I’m not sure I really have a lot of faith in trusting them to deal with my complications.  (And I don’t think this is necessarily unique to this one student health center, certainly my prior experience suggests otherwise)  So now that, that’s out there…

I got a recommendation for a primary care doctor, but when I tried to get an appointment with her, I was told she was no longer accepting new patients.  Strike one.  When I called to get an appointment with the rheumatologist I wanted, I wasn’t able to get an appointment until the beginning of December.  Strike two.      

But that was a function of me not having my new insurance information until the beginning of September – and the student health center being unwillingly to help me set up care over the summer – because I think I’d be crazy if I tried to suggest that there is a shortage of doctors in New York City.

Anyway, I was able to pick a different primary care doctor, who I was able to see a few weeks ago, and she gave me a recommendation for another rheumatologist, who I will be seeing at the beginning of November.

So far, I’ve noticed some major differences from the care that I had previously that I am pretty impressed with:

They actually – both doctors and support staff – know how to use their electronic medical records (EMR) system.  My previous care team, a year into using the system, still had no clue what they were doing, and this caused a lot of extra work for me.  But my new care, not only do they push the system on patients, but they actually utilize it, and do it well!  And it’s funny because they actually use the same system that my previous doctors use.

In New York, while I was able to transfer my prescriptions, I was told that they only allow one refill with the transfer, so I would need to get new prescriptions.  My doctor submitted all of them directly to my new pharmacy so they will be there when I need refills. 

Another major difference was that my blood was drawn in the exam room, rather than being sent to a lab somewhere else, either onsite or offsite.  That’s a nice change! 

I also didn’t feel like a sick person.  Maybe that’s a weird thing to say, but I didn’t.  Maybe part of it was the fact that I didn’t have to go sit in the waiting room of a lab where I was the youngest person, and everyone looked at me with pity.    

Every time I call to get an appointment, as soon as I give them my information, they say How can we help you today, Miss Rott?  I don’t feel like I ever got that kind of respect from my previous medical care team.  In fact, the support staff were usually pretty disrespectful, if not downright mean. 

And so I have to wonder, what’s the difference?

As my boyfriend pointed out to me, there are several major hospitals in the area, and because they are competing for patients, the quality of care and treatment that patients receive is better than it might be elsewhere.  For example, where we lived previously, there was really only one game in town as far as a major teaching hospital was concerned, and so, knowing this, I think they skimped a bit sometimes.  Or maybe they just didn’t care because they knew they were the only game in town. 

It’s not necessarily that I didn’t receive good care, but the extra touches weren’t there.  And I guess I didn’t really know they weren’t there until I now have care where they actually exist. 

Sometimes change is a good thing!  And sometimes a little competition is healthy!  

The Trials And Tribulations Of Electronic Medical Records And E-Prescribing* **

So, every once in awhile, I move away from posts that are extremely personal, emotional, and philosophical, to talk about the more practical aspects of being a patient, with some old-fashioned research thrown in for good measure.  

Electronic Medical Records

Recently, the hospital that my rheum and other specialists are at, and the student clinic where my primary care doctor is, moved to an electronic medical records system. 

At your first appointment after the system was instituted, you received an access code, which allowed you to go online and access your medical records.  You don’t have to, but for someone like me who is chronically ill, the possibility of having my medical information at my fingertips was very appealing.  So I signed up pretty much right away.

Until I discovered that there was an IPhone App I could download, I did not realize that the system I was using is actually of the “Vendor Created, System Hosted” variety (Halamka, et al. 2008).  This means that a third party created the system and the health system I belong to hosts it. 

In other words, Epic Systems, a company out of Wisconsin, created an electronic records system, known as MyChart.  This system has been around since the late 1990s. Along with Halamka, et al. (2008), Hassol, et al. (2004) and Serrato, Retecki, and Schmidt (2007) look specifically at the MyChart system.

Through the patient portal online, you can do a variety of things: request and cancel appointments, request prescription renewals, review health history, view immunization records, view test results, send messages to your healthcare team, and pay bills online. 

Here are some of my observations thus far:    

Likes:

-         You can create tables that compare past test results, which is useful to monitor certain levels.

-         I can e-mail my doctors’ offices, schedule appointments, cancel appointments, etc.

-         I get an automated e-mail when new results, messages, appointments, are posted.

-         Unlike before, both the hospital and the student health center can see records.  Before, only one could see all records and the other could not, which made things very tricky when you have a primary care doctor at one and all your specialists at the other.  This was a serious flaw in the old system, which I am grateful has been fixed.

-         Presumably no more having to pay money to get your hands on your medical records and test results. 

Dislikes:

-         I can only see my records/history from AFTER the system went into effect.  Presumably, the interface that my doctors use allows them to see the entire health record, not just since the implementation of the new system, but I am not certain of this, since I have never seen the system from the other side.

 

-         No one, in terms of doctors, knows how to use the system, which has increased the time of clinic visits by a significant degree.  It was instituted in the summer and there is still a steep learning curve, which I know has also been frustrating for the clinicians.

-         If there was some potentially devastating test result, would it get posted to the health record that the patient could interface with?  Or would it not be released until the doctor delivered the news to the patient?

-         I don’t kn0w what every test means.  I know certain levels and things like that, but not every test.

-         One of my medications is not commercially available in the United States, and therefore, was not in the database.  I was told the system would not allow the doctor to enter a medication not already in the system.  This seems like a huge liability, especially as far as drug interactions go.

-         There are some inconsistencies.  For one thing, the prescribing doctor on most of my medications is incorrect.  But there is no way to change things.  While you can interface with the medical record, as the patient, to my knowledge, you cannot manipulate it, even when you find things that are incorrect.

In their study, Hassol, et al. (2004) found that a third of people felt that their medical record and information was not complete.  Further, there was a distinct inability to understand tests results, especially abnormal ones.  Further, Hassol, et al. (2004) confirm my worst fears that patients can see any and all test results, even ones that are potentially devastating, before their doctor has had a chance to contact them about them directly.

One would hope that one benefit of having access to an electronic records system is that there would be greater coordination of care across specialists for the same patient.  However, this has been identified as one area that is lacking (O’Malley, et al. 2009). 

This is something I have noticed generally about my care, and something that I hoped would be improved by this system.  As I suggested, now all of my doctors in the same health system have access to my records, however, whether doctors put that information to good use is up to them.  Additionally, when I saw my PCP last week, she was very frustrated because there has been a variety of contacts (via phone and e-mail and through the portal) made between me and various doctors’ offices in the past month, and my PCP was having difficulty finding the last note she had made in my record when I saw her a month ago.

Negatives on a broader scope include electronic medical records widening the healthcare disparity based on race, as whites are much more likely to utilize these systems than are blacks and other minorities (Goel, et al. 2011; Roblin, et al. 2009).  Additionally, there are various privacy concerns due to the potential negative effects of the wrong people gaining access to electronic record information (Li, et al. 2011).

I have to say that I like the ability to e-mail questions, refill requests, and requests for making and canceling appointments online.  It saves me the hassle of going through my phone to find the doctor’s office number, of which I have many, and waiting on hold on the phone to talk to a person.  However, when doing things via the portal, this then puts the onus on the doctor’s office to contact the patient in regard to whatever message or request they have sent, rather than it being the patient’s responsibility.   

It may or may not be surprising then that Hassol, et al. (2004) found that patients preferred online communication the best, while doctors preferred telephone and in-person communication in preference to online. 

E-Prescribing 

Even before the adoption of the electronic records system was instituted in my health system, prescriptions went paperless.  Prescriptions are all electronic, so not only does the patient not have a paper copy of the prescription, but if there is an error, the patient won’t necessarily be able to catch it, because they don’t really get the opportunity to view the prescription that gets put into the system by the clinician.

I have had varying issues with this, as well:

-         My original Humira dose was totally wrong.  It somehow got listed as being taken twice a week instead of twice a month, necessitating the pharmacy to call my doctor to correct the error.

-         The prescription gets sent to the wrong pharmacy.  This has happened almost every time, and has involved me needing to contact the doctors’ offices to get the prescriptions re-submitted to the correct pharmacy.  Unfortunately, the way my prescription insurance works, I can’t get all of my prescriptions from the same pharmacy.  The “normal” ones I get at CVS, the Quinacrine I have to get from a specialty pharmacy that compounds, and certain other special prescriptions I have to get from the hospital pharmacy.  This system might be ideal for patients who are able to use one pharmacy for all their medications, but it seems to me that if you use more than one, it really complicates things.

-         It defaults.  So for the Humira, when I was trying to get the pre-filled syringe instead of the pen, it automatically selects the pen and the nurse or clinician had to notice this and change it, which didn’t happen, again necessitating contacting the doctor’s office multiple times to make the change.

I am not sure of the specific E-Prescribing system that is used by my healthcare providers, but whichever one it is, I have noted above the various problems that I have experienced.

While some have suggested greater efficiency with E-Prescribing (Agarwal, et al. 2010; Grossman, et al. 2012), E-Prescribing actually tends to take doctors longer than simply handwriting them (Lapane, et al. 2011), and can increase, rather than decrease, the amount of errors made that can have adverse consequences on patients (Palchuk, et al. 2010).

The thing I really don’t like about this system, with all of its flaws, is that there is no way to get a paper prescription.  Even when the prescription keeps getting messed up.  And there is no way to see this, because you never see what the physician is putting into the system.  I’m all for technology, but to be so technologically dependent, even when there are clear errors, is just plain annoying. 

A lot of problems in E-Prescribing occur when there is a lack of technical support (Crosson, et al. 2011), suggesting that adequate training of healthcare workers is needed, and adequate support needs to be provided when problems occur.

I’m not trying to be a Negative Nancy here, but of course, all of this presupposes that the patient has adequate internet access and is technologically savvy enough to use the systems.  And the doctors have to be technically savvy, as well, which may make it difficult to learn a totally new system while having a regular caseload of patients. 

If your healthcare providers haven’t hopped on the electronic health bandwagon yet, it is only a matter of time.  But given all of the issues that I and previous research has noted, the bottom line is that these systems are only as good as the people that created them and the doctors and other medical personnel that use them.

These are screenshots from my IPhone of the sign-in screen to my health system-specific portal (left) and the actual interface of the MyChart capabilities (right).  

These systems look quite different between the IPhone interface and the PC interface, so I have also included screenshots of the sign-in screen (top) and interface (bottom) as they appear on my PC.  Without showing too much of my personal health information, I wanted you to see all the various things you can do with the portal.

 * I’ve excluded from analysis articles that come out of the UK and Canada, as their healthcare systems, as they currently stand, are different from ours.

**For this I looked specifically at research related to electronic health records and E-Prescribing, rather than health informatics, in general, for which there is a large literature.

References

Adler, K.G. 2009. “E-Prescribing: Why the Fuss?” Family Practice Management (January/February) 2009: 22-27.

Agarwal, R, C.M. Angst, C.M. DesRoches, and M.A. Fischer. 2010. “Technological Viewpoints (Frames) About Electronic Prescribing in Physician Practices.” Journal of the American Medical Informatics Association 17: 425-431.

Crosson, J.C., R.S. Etz, S. Wu, S.G. Straus, D. Eisenman, and D.S. Bell. 2011. “Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices.” Annals of Family Medicine 9 (5): 392-397.

Goel, M.S., T.L Brown, A. Williams, R. Hasnain-Wynia, J.A. Thompson, and D.W. Baker. 2011. “Disparities in Enrollment and Use of an Electronic Patient Portal.” Journal of General Internal Medicine 26 (10): 1112-1116.

Grossman, J.M., D.A. Cross, E.R. Boukus, and G.R. Cohen. 2012. “Transmitting and Processing Electronic Prescriptions: Experiences of Physician Practices and Pharmacies.” Journal of the American Medical Informatics Association 19 (1): 353-359.

Halamka, J.D., K.D. Mandl, and P.C. Tang. 2008. “Early Experiences with Personal Health Records.” Journal of the American Medical Informatics Association 15 (1): 1-7.

Hassol, A., J.M. Walker, D. Kidder, K. Rokita, D. Young, S. Pierdon, D. Deitz, S. Kuck, and E. Ortiz . 2004. “Patient Experiences and Attitudes about Access to a Patient Electronic Heath Care Record and Linked Web Messaging.” Journal of the American Medical Informatics Association 11 (6): 505-513. 

Lapane, K.L., R.K. Rosen, and C. Dube. 2011. “Perceptions of E-Prescribing Efficiencies and Inefficiencies in Ambulatory Care.” International Journal of Medical Informatics 80: 39-46.

Li, F., X. Zou, P. Liu, and J.Y. Chen. 2011. “New Threats to Health Data Privacy.” BMC Bioinformatics 12: 1-7.

O’Malley, A.S., J.M. Grossman, G.R. Cohen, N.M. Kemper, and H.H. Pham. 2009. “Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices.” Journal of General Internal Medicine 25 (3): 177-185.

Palchuk, M.B., E.A. Fang, J.M. Cygielnik, M. Labreche, M. Shubina, H.Z. Ramelson, C. Hamann, C. Broverman, J.S. Einbinder, and A. Turchin. 2010. “An Unintended Consequence of Electronic Prescriptions: Prevalence and Impact of Internal Discrepancies. Journal of the American Medical Informatics Association 17: 472-476.

Roblin, D.W., T.K. Houston, J.J. Allison, P.J. Joski, and E.R. Becker. 2009. “Disparities in Use of a Personal Health Record in a Managed Care Organization.” Journal of the American Medical Informatics Association 16 (5): 683-689. 

Serrato, C.A., S. Retecki, and D.E. Schmidt. 2007. “MyChart – A New Mode of Care Delivery: 2005 Personal Health Link Research Report.” The Permanente Journal 11 (2): 14-20.