My hospital-based practice with electronic medical records does have a patient site program where you're supposed to be able to look at your test results and send secure messages. I'd really like to be able to look at my test results online--particularly since my doctor tends to just have the letter that says my results were normal. (She does go over them when I see her.) But she won't participate, since it would take up too much of her time.
I'm just going to save reading and commenting on this post for later, after I've taken care of hot sauce and sappy stories.
I usually wind up talking to one of the nurses who supports her--not the nurse parctitioners who actually see patients--and I'm pretty sure that they just log in as her to fax my BC prescription to the pharmacy.
Judging from the experience of my friends in the profession*, they are probably worried about spending an extra 3 hours a day answering emails -- especially where patients might take advantage of email rather than paying for an office visit. Yeah, they can be screened by a nurse just like phone calls, but people often feel a little more hesitant to *call* to ask a stupid question, but not so much with email.
* Mostly the spouse of a friend in the profession Dr. Spouse is ridiculously available to his patients by phone, which the patient loves and my friend sort of hates.
Also, although regs are changing for some things, they can't bill the insurance when they don't see you. I think that some mental health providers are getting paid for case management stuff, but that's mostly from Medicaid.
1: That sounds awesome! Yeah, I really hate the generic "your results were normal" thing. I want numbers, dammit, so I can go on the internet and second guess you!!
they are probably worried about spending an extra 3 hours a day answering emails -- especially where patients might take advantage of email rather than paying for an office visit.
I'm sure this is it exactly, but what poor customer service, srsly.
Here in the UK nurses wouldn't waste their time screening emails or dealing with phone calls. There are admin staff for that.
There are admin staff for that
They don't answer phones here, either. But I said filter the e-mails administrator -> nurse -> doctor.
Out of curiousity, is there a way to shoot out an e-mail for an idle concern to your doctor in the UK?
8: Not here either. What I meant to say was that I've never talked to my primary care physician on the phone. I usually just speak to an administrative assistant. But once I had an infection, and the treatment that the nurse practitioner prescribed didn't work fully, so I was transferred to a nurse, who asked me why I hadn't been prescribed X. (Actually the NP wanted to prescribe something else, but I had to try the other OTC thing with a prescription first.) I said that it was because the NP said that there were drug interactions. The nurse said that no interactions popped up on the computer, btu she would speak to my doctor and call me back. Then the nurse faxed in the script, but it said that my doctor prescribed it.
Our pediatrician says his office doesn't use email because of privacy concerns, for what that's worth. But they do have a pretty good system for dealing with questions: you call and leave a message, and a nurse calls you back with an hour with an answer or follow-up questions, as needed. Sometimes, you even get the doctor on the phone.
I'm sure this is it exactly, but what poor customer service, srsly.
See, there needs to be a way that the doctor makes whatever s/he is going to make regardless of how many times you come in to the actual office.
Hi Dr. X--
I'm having some chest pains and my arms are kind of numb. Is this something I need to see you about, and if so, could I maybe get an appointment next week?
Patient Y
One of my doctors uses a service called RelayHealth, which is a secure password protected website to post test results, messages to patients, and even schedule appointments (although my doctor discourages that one - negotiating a time to come in that works with everyone's schedules is actually faster over the phone). I think it's through her hospital, but I'm always surprised that she's the only one that does this.
Of course, my GP gets in at 6am every day to personally call people with their test results before patients arrive, so that works too...
re: 9
I can't email my GP, no. There are general email contacts for some of the medical services I use. But I think they primarily function for arranging appointments, that sort of thing.
We do have a thing called NHS direct, though. Which is a hotline for the NHS. You phone, you speak to a call-centre worker. You describe your problem and they get a nurse to call you back. If the nurse thinks you need to speak to a doctor they arrange it, or if they think you need to see someone in person, they can deal with that too.
11: I actually worry more about leaving a message about a prescription refill with the random admin person on the phone.
12: Beth Israel (where I go), and I think that MGH and the Brigham have similar set-ups. The CEO of BIDMC has a blog about how cognitive specialists (not just primary care, but non-interventionist cardiologists who don't do procedures) need to get paid more, because they're the ones who keep us healthy, and that their time outside of office visits needs to be compensated.
I mean, capitation (a lump sum for each patient) would do this, since the doctor would deal with things over the phone if tehy could to free up more time so that they could hav emore patients, but people complain that there's too much of an incentive to deny people care under that system. Medicare is looking into Pay for Performance, but it's tricky. They're also starting not to pay for events that shouldn't happen. You take out the wrong kidney, you don't get reimbursed for the surgery.
15: I totally don't trust those people, though.
I did e-mail a fellow at the Sleep Clinic about a quasi-administrative matter, because that was teh fastest way around the issue. He gave me certain numbers, and I called the insurance to check whether they would cover something, and they wouldn't tell me. They said that they had to speak with the doctor, so I told him that.
15.---Kaiser has something like that, too.
For the foreigners: Kaiser is a insurer/hospital/medical network monolith that has been touted as one possible model for a more universal US health system. My parents have been covered under my dad's employment, and I never really had a problem with the waiting rooms and restrictions on appointments and whatnot.
Out here in New York, everyone seems to go either to public/non-profit clinics or to private doctors in weird poky offices with ridiculously posh addresses. I went to a private doctor once, was flabbergasted at the price, appalled with the poor follow-up care, and vowed to stick to the public clinics for a while at least.
All of these systems (listed in 16) are predicated on a total lack of trust of doctors and the assumption that doctors will try to exploit any billing mechanism. Which may possibly be true of too many doctors at the moment, (but I doubt it) and I certainly don't think that's intrinsic to a health care system.
There's got to be some sort of reasonable oversight mechanism which allows doctors sign up for (say) 40-50 hours per week, and pass on their case load amongst each other if they're not able to keep up, and take on each others cases if all their patients are doing well.
It is all about the money. Lawyers face this all the time. People want to call me all day to "just ask a simple question." And, why would I charge them for a simple question?
If they are a client with a retainer, it is easy.
I could spend all day on simple, free questions.
Doctors are the same way. Plus, if you send an email and they dont respond quickly and something bad happens to you, the lawyers get involved.
20: None of that makes this an efficient system.
Kaiser is in DC too.
When Harvard Pilgrim was Harvard Community Health, an idealistic non-profit HMO, they did something similar. Unlike Kaiser, they never ran their own hospitals.
20: On the flip side, people used to complain about lawyers calling up about some business matter, spending too much time chatting and then billing for the whole time.
I will agree that I much prefer emails to calls from my clients.
They can organize their thoughts and I do not have to hastily write down their stream of consciousness ramblings and rants.
All of these systems (listed in 16) are predicated on a total lack of trust of doctors and the assumption that doctors will try to exploit any billing mechanism.
It's not a coincidence that the only other place I've seen the word "capitation" before BG's comment is in case law addressing the ability to sue HMOs for malpractice. Businesses are set up to make profits, and if the net income is a flat rate, then the best way to maximize profits is to minimize expenses. And the best way to minimize expenses is to minimize services provided.
Even good, conscientious doctors are going to have a hard time balancing their practice as a business and their practice as the exercise of a profession.
Plus, if you send an email and they dont respond quickly and something bad happens to you, the lawyers get involved.
Which, come to think of it, would keep alot of my friends employed.... Hmm....
Businesses are set up to make profits, and if the net income is a flat rate, then the best way to maximize profits is to minimize expenses. And the best way to minimize expenses is to minimize services provided.
Which is exactly how my dad explained to me why we need socialized medicine, back when I was a wee-monkey.
Hm, I guess the one benefit of having to deal with the crappy university health clinic is that the doctors will hand out their cards with email addresses and tell you to email them if you have any questions. They also have an advice nurse hotline, though that kind of sucks because it's only available during business hours. Inevitably, I get sick on the weekends, and the health center isn't even OPEN then. Bah.
Also, I'm led to understand that Kaiser also has a 24 hour advice nurse system that's pretty helpful, as well as all of the patient records online on a secure server.
28: Okay, but only as long as it doesn't interfere with lawsuits.
28: Except that if you can't make profits, you can still make your life a lot easier by doing as little as possible if you get a capitated rate. Probably a smaller issue, but human nature is what it is.
28: You can still have this problem in socialized systems. GPs in the UK, unlike consultants/specialists are self-employed and get paid by the government. Some are super conscientious and some load up on patients and make salaried locums take on extra work.
In Canada, it's fee for service and isn't really socialized except in the sense that it's social insurance. It's just like having one insurance company. I don't know how this affects practice patterns.
Kaiser also has a 24 hour advice nurse system that's pretty helpful, as well as all of the patient records online on a secure server.
It seems to have had such since I was very young, although surely the records were paper back then. But seriously, at 18 or 19 I was treated by a Kaiser doctor in Southern California who had access to all of my Northern Californian medical records. So.
31: So what you need is a capitated rate, but really fierce competition for patients.
33: And at least now you can access them yourself as well. At least I think you can. All of my knowledge about Kaiser comes from an actual Kaiser employee and I'm never sure which benefits are for all and which come from working for them.
34: In other words either train too many doctors or set the capitated rate so high that even with a fairly sick patient you get more money out of it than if you were getting fee for service?
Why can't everyone in every profession just not act like jerks determined to exploit the system, and we can all have a functional efficient result where we trust each other to act in good faith becaue we're not jerks?
Saith the Rodney King of south-central Texas.
Hee. Would you be my Reginald Denny?
My last doctor told me, at our first meeting, "I'm unfortunately often difficult to reach by phone, since I'm in and out with patients all day. So if you ever have any questions, here's my email address." [Hands me card.] "It's much easier for me to reply to emails in-between patients than it is for me to return phone calls."
This seemed completely normal/reasonable at the time, and only later did I realize that I'd never had another doctor do it before or since.
Since we are ranting. Why did my chain tensioner have to break at the beginning of some of the best biking weather we have had in the last couple months. Now I have to see if I can rig up an old derailleur or order a new tensioner which will mean missing a week of riding.
Not quite on the level of broken health care systems, but still annoying to me personally.
I know some psych residents who give out their e-mail. Some of them even give out their pager numbers, but some of them only use those for absolute emergencies.
BTW, Brock, how's your health? Any clear-cut diagnosis. Are you eating enough fiber?
Probably, some Privacy Officer like me told the docs to avoid e-mail with patients as much as possible because of security and privacy issues and the inherent insecurity of e-mail. The HIPAA Security rule says that electronic protected health information should be encrypted, and it's very difficult to send an encrypted e-mail to patients. (Conversely, the HIPAA Privacy rule says that patients can ask for specific modes of communication, including e-mail, and I've never been able to adequately marry the two rules.) Additionally, telemedicine regs from state to state require all sorts of documentation of electronic coorespondence, and stuff in a doc's e-mail box may never make it into the medical record. The solution a lot of clinics have come up with is to set up some sort of portal system, where the patient can be authenticated, log on to the secure, encrypted system, communicate through the system's messaging tool. It's slightly more labor intensive on the patient side than using e-mail, but the benefit is that patients can use the portal for other things, like setting up appointments, checking on test results (if that is a feature the clinic has decided to turn on), and asking for refills. I suspect as more and more clinics move over to EMRs, these sort of solutions will become more widespread.
39: Much more romantic to randomly surprise me with that question while I'm stopped at an intersection or something.
Decapitate the capitators! Fee for service or Death!
Some of the problem here comes from the messed up authority structure in medicine. Doctors are set up as the sole decision maker and authority (often even excluding the patient from the process) and then find that they don't have the time to make all the judgments they have to make.
Heebie's set of filters--administrators and nurses read email before doctors--would be effective if the administrators and nurses had access to all the information the doctor does and were trusted to make basic judgments.
Similar problems are probably why 24-hour nurse help lines aren't more widely available.
Back when I had a GP under the OMGSOCIALISM Canadian system, he was an older guy (over 60) who didn't do email, which was fine, but I could call and he'd call back when he had a chance. So I asked him questions and avoided a couple of visits that way. This same guy once sent me a stack of papers he'd read in response to one issue I was having, with highlighter all over the place, just cause he knew I was interested in the science.
I'm amazed (and pleased) that no one has yet blamed trial lawyers , since IME the probability rapidly approaches 1 that someone will blame trial lawyers for every conceivable problem with the medical system.
As I understand it, the medical system in general has had huge problems getting on board with all sorts of computerized information systems. That's pretty interesting -- esp. given the readiness to of doctors to adopt all sorts of other medical technology. But I have no idea why. Maybe HIPAA is really to blame, but this doesn't seem to be a US-only problem.
47: I think that nurses have some decision-making capabilities, and I know that they have access to my medical records.
I'm amazed (and pleased) that no one has yet blamed trial lawyers , since IME the probability rapidly approaches 1 that someone will blame trial lawyers for every conceivable problem with the medical system.
There are enough trial lawyers and smart people hanging around here to know better.
Trial lawyers are mere pikers in the screwing-up-medicine game really. They can learn a lot from pharma and insurance companies.
esp. given the readiness to of doctors to adopt all sorts of other medical technology
This actually isnt' true. Younger ones do, but physicians are very conservative about technologies.
Insurance (malpractice, not health) companies and legal council are also concerned about technology, which doesn't help. I once worked on a industry product where one of the necessary selling points was that it didn't record any information, anywhere.
As far as computerized records go, it's mostly an issue of who has access and who doesn't and how. There are are a lot of laws to run afoul of if you aren't careful, and the low tech system at least hobbles along in a known way.
There are a lot of tricky issues, too, if we're including hospital records. You need either to be able to put information into the record from a patient's bedside; or have a totally unrealistic number of admins transferring paper notes into the electronic system, for example. What you really don't want is a set of electronic medical records that you think has everything in it, but there's really also a folder of scribbled notes that's important too.
If you live in the bay area and maybe some other places, try the Metropolitan Medical Center (www.metropolitan.md). I'm not getting paid by them to say this but I'm a patient there and you pay $100/year to "join", and in exchange you get direct email access to doctors and can usually get same-day appointments if you call/email. It's awesome imho and well worth it. They may have other branches elsewhere, too.
a .md domain? Be careful, Moldova is lawless.
Insurance (malpractice, not health) companies and legal council are also concerned about technology, which doesn't help. I once worked on a industry product where one of the necessary selling points was that it didn't record any information, anywhere.
I find (generally) that this kind of paranoia in the medical world is baffling. You know what's really hard? Collecting any money from a medical malpractice suit (trust me). You know who else has to worry about being sued? Every other industry, yet those industries somehow manage to record information, set up standards and practices, and even (gasp!) admit to problems or mistakes. I really do think there's something cultural about the medical profession that makes the fear of lawsuits more visceral than rational -- perhaps its a resistance to or fear of having one's methods cross-examined, perhaps it's just general insurance company stupidity, or perhaps its that malpractice premiums are a specific and visible expense for doctor's private practices.
Why can't everyone in every profession just not act like jerks determined to exploit the system, and we can all have a functional efficient result where we trust each other to act in good faith becaue we're not jerks?
I heard it has something to do with apples and snakes.
You know who else has to worry about being sued? Every other industry, yet those industries somehow manage to record information, set up standards and practices, and even (gasp!) admit to problems or mistakes.
While I think I agree, you're overstating the case. How many other industries deal with anything approaching the potential third-party liability of doctors? (Both from genuine mistakes (which are a normal, unavoidable part of practice--there are better and worse doctors, but many doctors are just lucky if your mistakes don't badly hurt anyone, and unlucky if they do), and from unavoidable bad outcomes (that can still lead to very expensive litigation)? I can't think of any. Trucking might be closest, but I bet it's not very close.
Dr's utilizing electronic records would face the same sorts of issues as anyone storing electronic records containing sensitive information (which is most large businesses), but that's a significant potential liability they'd be adding on top of all their other significant potential liabilities. And they also (argubly) hold more extensive, and more sensitive information than many other businesses (banking might be the lone exception), so their potential exposure here could be relatively high.
This actually isnt' true. Younger ones do, but physicians are very conservative about technologies.
Insurance (malpractice, not health) companies and legal council are also concerned about technology, which doesn't help. I once worked on a industry product where one of the necessary selling points was that it didn't record any information, anywhere.
As far as computerized records go, it's mostly an issue of who has access and who doesn't and how. There are are a lot of laws to run afoul of if you aren't careful, and the low tech system at least hobbles along in a known way.
I've read of hospitals / practices going electronic and later going back to paper, because becoming more efficient reduced unnecessary care, which lowered revenue. This will be an issue as long as our system is set up to pay for treatments rather than health. (Plus it can embarrass doctors by making stupid mistakes more discoverable.)
Grammatical question, possibly related, that came up the other day: is my instinct correct that one says a doctor works at or in a hospital, rather than for it?
While 60 could plausibly be a situation somewhere in the US, I know that hospitals have had trouble with the switch in areas where no such potential incentive exists. Medical records are just difficult. LB noted the bedside problem, and there are others.
is my instinct correct that one says a doctor works at or in a hospital, rather than for it?
This really depends where you are, if you are thinking of the technical differences between being salaried by a hospital, or billing through it.
"How many other industries deal with anything approaching the potential third-party liability of doctors? "
Journalism? Not such a problem in the US, but here in the UK we live in constant fear of being sued. I'm lucky in that I work for a company which has expensive insurance and expensive lawyers and which will fight my corner if I fuck up or am just unlucky, but not everyone does.
This really depends where you are, if you are thinking of the technical differences between being salaried by a hospital, or billing through it.
No, speaking generally. Somehow when I was editing a document it felt wrong to say "working for" - as if it was beneath doctors to toil for wages.
Even without knowing a thing about it, I have a very hard time that journalists in the UK face anything like the potential exposure of doctors in the US. It's not just the ever-present stream of claims, which lots of industries face, but also the size of the potential damages.
59, sure, doctors have special liabilities, but it's much easier to bring almost any other kind of tort suit than it is to bring a medical malpractice claim -- and that has been true for 50 years, even before the recent trend of damages caps that now make med/mal cases almost impossible in some jurisdictions (including Heebie's home state of Texas). Airlines are another industry where relatively minor failings can lead to certain death and multi-million dollar tort claims, but the airlines aren't driven by fear of lawsuits in the same way that the medical industry seems to be. Damages for e.g., securities fraud or breach of contract business cases dwarf med/mal liability, and yet the culture is different there, too. The broader point is that the fear of lawsuits amongst doctors/medical insurers appears, to me, to be way out of proportion to the risk.
as if it was beneath doctors to toil for wages.
Only some of them wish this were true.
The broader point is that the fear of lawsuits amongst doctors/medical insurers appears, to me, to be way out of proportion to the risk.
Otoh, nobody is offering pilots, flight attendants and engine mechanics 100-200k raises to cover insurance, right?
63: It really does depend. Some doctors are employees of the hospitals where they work and some aren't. If the doctor is an employee, "works for" is perfectly correct and appropriate. If not, not.
62, 64: Part of it is probably just that medicine is a very complex, highly regulated industry with lots of people in it who spend all their time trying to prevent various sorts of Bad Legal Stuff from happening. In that kind of environment, Bad Legal Stuff becomes part of what you spend your time worrying about.
Another piece has to be the social element. Being sued for malpractice means having your professional performance and competence attacked in a forum where you're not the professional in control. Having a very strong norm within your own peer group that malpractice suits are an abomination helps to get through that.
64: Journalism in the UK is a special case.
If AWB's experiences with her student's emails is any hint, I'll bet MD's offices would be snowed under by questions prompted by visits to screwy "medical" sites. "If eating prunes is good for constipation, wouldn't shoving them up my ass work even better?
Re efficiency of care. Sometimes it's amazingly, surprisingly good. I signed up for a Medicare D plan for the one drug I take, and it was on their Tier 2. Also, they want you to try something cheaper first and they limit the quantities to 30 days if they do give the stuff to you.
I downloaded their exemption form, took it to the doc, and had company approval for the stuff in 90 day quantities the next day.
I called the mail order Rx company, told them what I wanted, they called the doc, and I got shipping confirmation a few days after.
I'm boggled at how smoothly this all went. It raises my suspicions, I'm thinking they're going to send me mis-labeled Zyclon B tablets.
I'm close to looking for another doctor because of these kinds of issues, only I have no idea how I'd find another one where these problems wouldn't crop up. I had to have some tests done this summer. When I called for the results, they gave me over to the doctor's assistant, not an MD. This person could only tell me that the results were in but couldn't interpret them. But then he said I needed another test, and it wasn't unreasonable to interpret the next test as an indication that there was something wrong (potentially cancerous) in the previous test. So then it's phone tag for three days. When I finally get the doctor, she's like, "No, previous test is totally groovy, they just happened to see something else on the MRI that has nothing to do with it, probably nothing in and of itself, but let's look". So another test, and that's no problem either, but again the phone tag and evasive answers and confusing messages.
I should not have to schedule an appointment to get results unless said results indicate that there's something that's going to need treatment or a situation that needs detailed discussion.
I love how people talk about places where there's public health care where you have to wait for appointments, etc. With my HMO coverage, I can't beg borrow or plead for more than two minutes of my doctor's time, I get seen in a highly time-rationed way when I get in, and it is entirely possible that if I had a serious problem, it would fall in between the cracks. This is more or less the same as having to wait for a period of time--it's just apportioned in a slightly different way.
I've got a specialist who it takes three months to get in to see. So she wants me to call her while we work on adjusting some meds. Specifically, I can have her paged on alternate Fridays.
Email would be good.
Here we can use an e-mail-like system for submitting common queries that can go to the doctor and the doctor's fleet of nurses. It works well for quick questions of the sort heebie would have as well as refills. It's eminently sensible.
Journalists in England and Wales* face some of the harshest defamation laws in the world; if you ever want to sue someone for defamation, find out a way to do it under English law.
* but I don't know the details about Scotland.
I'm willing to bet that the average UK libel award is higher than the average US malpractice award as a proportion of the defendant's salary. Hell, it's probably larger in absolute terms.