EMR Alert – Featuring radiologist note in illegible font color
For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.
I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.
I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.
This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.
While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.
What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?
Would allowing patients to read their mental health notes provide more benefits than risks?
In a recent article in JAMA my colleagues and I argue that it would. While transparent medical records are gaining favor in primary care settings throughout the country through the OpenNotes initiative, there has been reluctance to allow patients to see what their treaters say about their mental health issues. While this reluctance is understandable and deserves careful consideration, we suggest that several benefits could result from patients reading their mental health notes.
First of all, accuracy would be enhanced by allowing patients to cross-check what their clinicians say about their symptoms, medication doses, and so forth. Second, allowing patients to review assessments and treatment decisions privately might help to promote a richer dialogue between patient and clinician. Third, patients might learn that their clinician sees them more as a complete person, rather than as a collection of symptoms.
Many patients silently fear that their treater “will think I’m crazy/whining/lazy/boring”; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.
Clinicians have their own worries about transparent mental health notes that must be considered. Will patients feel objectified by the medical language commonly used in documentation? Will they break off treatment if they don’t like what they read? Will too much time be spent wrangling over details of what has been documented? Will vulnerable patients be psychologically harmed by reading their notes? Although our article briefly addresses these issues, only a trial of transparent mental health notes will provide the data needed to assess them.
Such a trial has just begun at the Beth Israel Deaconess Medical Center in Boston. Culminating many months of careful planning by my colleagues in the ambulatory psychiatry clinic, the Social Work department, as well as the OpenNotes team, we began a pilot project of transparent notes in our psychiatry clinic on March 1. So far almost all clinicians have chosen to participate in the project, and have identified 10% of their caseloads to be included. It’s too early to gauge results yet, but we hope to more fully evaluate the effects of making mental health notes fully transparent to our patients.
Michael W. Kahn, MD is an assistant professor of psychiatry at Harvard Medical School and Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center (BIDMC).
T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.
He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.
A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.
He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.
The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.
His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.
T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.
Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.
However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.
They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.
Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.
However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.
Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.
When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.
The Obama administration announced significant adoption for the Blue Button in the private sector on Friday.
In a post at the White House Office of Science and Technology blog, Nick Sinai, U.S. deputy chief technology officer and Adam Dole, a Presidential Innovation Fellow at the U.S. Department of Health and Human Services, listed major pharmacies and retailers joining the Blue Button initiative, which enables people to download a personal health record in an open, machine-readable electronic format:
“These commitments from some of the Nation’s largest retail pharmacy chains and associations promise to provide a growing number of patients with easy and secure access to their own personal pharmacy prescription history and allow them to check their medication history for accuracy, access prescription lists from multiple doctors, and securely share this information with their healthcare providers,” they wrote.
“As companies move towards standard formats and the ability to securely transmit this information electronically, Americans will be able to use their pharmacy records with new innovative software applications and services that can improve medication adherence, reduce dosing errors, prevent adverse drug interactions, and save lives.”
While I referred to the Blue Button obliquely at ReadWrite almost two years ago and in many other stories, I can’t help but wish that I’d finished my feature for Radar a year ago and written up a full analytical report.
Extending access to a downloadable personal health record to millions of Americans has been an important, steady shift that has largely gone unappreciated, despite reporting like Ina Fried’s regarding veterans getting downloadable health information.
According to the Office of the National Coordinator for Health IT, “more than 5.4 million veterans have now downloaded their Blue Button data and more than 500 companies and organizations in the private-sector have pledged to support it.”
You probably saw some of the headlines last week where Box announced that is supporting HIPAA and HITECH compliance, signing Business Associate Agreements, (BAAs) and integrating with several platform app partners such as Doximity, drchrono, TigerText, and Medigram to help seed its new healthcare ecosystem. I also announced that I was formally advising Box on their healthcare strategy.
I was drawn to Box because of all the lessons I learned at Google building a consumer-directed, personal health record (PHR), Google Health. Google Health allowed you to securely store, organize and share all of your medical records online and control where your data went and how it was managed. It was unlike the other PHRs in the industry that were tethered to the provider or payor or part of an Electronic Health Record (EHR) system.
Sound good? Well, it was in theory. The big issue with Google Health was aggregating your data from the disparate sources that stored data on you. We had to create a ton of point-to-point integrations with large health insurance companies, academic medical centers, hospitals, medical practices and retail pharmacy chains. All of these providers and payors were covered entities in the world of HIPAA and were required to verify a patient’s identity before releasing any data to them electronically. It was a very bumpy user experience for even the most super-charged, IT savvy consumer.
In November 2012, the digital team at HealthEd embarked on a challenge to redesign the face of personal health records. That effort has been rewarded with a first-place win in the category of Best Lab Summaries. And another HealthEd entry was cited as a finalist that “inspired the judges and challenged the status quo.”
About the Health Design Challenge
The Office of the National Coordinator of Health Information Technology and the Department of Veterans Affairs issued a challenge to designers throughout the United States: imagine how personal health records could be improved for clarity, readability, and visual appeal. Given HealthEd’s mission to create better outcomes in personal wellness, the team embraced the Health Design Challenge with typical enthusiasm.
The Health Design Challenge was more than an exercise in graphic design, however. Entrants were required to demonstrate expert knowledge of clinical systems and to render information of relevance for both millennials and senior citizens. The judges wanted more than pretty pictures—participants had to know their stuff.Continue reading…
Don’t assume anything.
Assumptions can kill.
Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you. Here’s my list of potentially harmful assumptions:
1. No news is good news
If you have a test done and don’t hear anything about the result, do not assume it is fine. This assumption kills people. I have too many patients with too much information flying at me every day for me to catch every important detail. Sometimes things are missed, but sometimes the results don’t come to our office. We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in. I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.