I AM too young to be familiar with fax machines. My parents had one, and I can vaguely remember them making fun of my grandfather’s skepticism of this “new” technology. I didn’t have to use one. That was until I started working in a hospital.

Now I use a fax machine almost daily, as well as other arcane technologies, such as the pager that has to be carried around at all times.

These rather quaint examples make for fun anecdotes to regale non-medical friends with, but they speak to something more profound: the generally abject quality of the communication tools employed by health care practitioners.

This is especially clear in our handling of medical records. It’s ironic, given that our profession takes so much pride in the ability to tell the story in a succinct and a systematic way, that we are so tolerant of platforms that obscure rather than illuminate the important points in a patient’s history.

Even within a single hospital network, the archive can be dense, chaotic and generally migraine-inducing. It’s not uncommon to find a crucial operation report hidden among a dozen computer-generated data logs or lost at the end of a digital cul-de-sac.

But the real problems start when records are scattered between public and private or across the territorial boundaries of local or state health networks. In this case, chasing the records feels like a fishing expedition, and there are days when the fish just aren’t biting.

Here’s a typical example. A patient who is cognitively-impaired is admitted with a vague history of a previous admission to another hospital following a fall, and it’s thought, reasonably, that retrieving those records may be useful to the current admission.

But on contacting that hospital, which is less than 100 km away, I find that I can’t even be told if those records exist, much less their content. The only way to find out is to start blindly faxing request forms out into the wilderness of medical records. That represents a dismal yield on an investment of considerable amounts of time.

These frequent trips down the rabbit hole in the search for records that may not even exist are really morale depleting. I was prepared by medical school for the stress of dealing with people who are sick. I wasn’t prepared for the task of cold-calling pathology labs around south-western Sydney on the off-chance of turning up an old blood test.

There has to be a better way.

For example, a visual representation of a patient’s encounters with the health care system: something akin to a Facebook-style timeline dotted with colourful icons for specialist appointments, hospital or intensive care unit admissions, GP visits, pathology tests and vaccinations.

A basic record of who a patient saw, and when, in order to capture the broad brushstrokes of a patient’s history and facilitate further enquiry if indicated. Medicare provides an existing imperative to collect these discrete data points. Mining that data and finding a way to meaningfully represent it seems like an obvious next step.

It is unlikely, for a whole host of reasons, that we’ll load everything to the “cloud” in the near future. Meanwhile, the hunt for patient records will go on, and one day, in the not too distant future, I will gladly hand that poisoned chalice over to doctors who are more junior than me.

However, right now, I’m the most junior and I’m tired of working each patient up from scratch because it’s often easier than finding and sifting through the records. It’s a duplication of labour when there’s a surplus of work already, work that I’d find much more rewarding than spending a couple of hours on the phone listening to Handel’s Water music.

James Dando is an intern at a major Sydney hospital.

 

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14 thoughts on “Why are we communicating so badly?

  1. Anonymous says:

    Whatever happened to the Patient Held Record?? From what I have been told (happy to hear otherwise) around 40% of Medicare eligible people registered for this (including me) but use is around 15%? And the ‘choice to upload’ nature means that one has no idea how rich the record is, or how deficient.
    I’ve no idea even how to access mine – or if a patient told me they have one, I don’t know how to access it. I guess there is an app?
    PS – I do acknowledge the debate about privacy and what a person wants to go into the hand-held record! But like James, I am chasing private U&Es every day…and asking “have you ever had a blood test for…”

  2. ex doctor says:

    In the pre-fax era one would resort to the steam telephone. The pathology operator would accept at face value that you were a doctor after a pathology result and report it without question. Where circumstances required, the pathologist or radiologist would come to the telephone. These were the days when one was expected and required to treat ethically, information exchanged by medical colleagues. Ethics are now dead and we live under the legislative yoke of the privacy law. The stories above are typical.
    Hard copy medical records now contain massive amounts of disorganised and irrelevant material courtesy of a medico-legal requirement to keep everything and have largely lost their clinical utility.
    Framing the law so that the misuse of information determines the breach of privacy would help. Recognising degrees of privacy might also help. What is so private about a patient’s serum potassium of 4.0mmol/l on 3rd January 2004?
    The most serious problem James has highlighted is that it is easier to repeat the expensive tests or imaging than to chase the records. I wonder when the framers of the rules will recognise that this is extremely expensive and bad medicine to boot.

  3. Ian Hargreaves says:

    While Mark Zuckerberg says that privacy is dead, most of us are reluctant to post on Facebook that we have had an abortion, a mental illness, a drug addiction, or a diagnosis of early Alzheimer’s disease.

    Unfortunately, the national privacy principles regard your yesterday’s sodium level showing hyponatraemia, as being as confidential as your HIV status or your history of STIs.

    Because of scams such as fake emails from the tax office or the bank, or those cold callers who tell you to go to your computer immediately or your Internet will be cut off for ever, it is understandable that the physical fax that comes from a reputable and searchable Public Hospital number is the most acceptable form of ‘secure’ communication.

    Putting the boot on the other foot, how many of us have told all of our own treating doctors to freely disclose our information to anyone who emails or calls saying “I am Dr X from hospital Z”, and how many of us carry with us at all times a paper medical history of at least all our treating doctors’ contact details, diagnoses, allergies and current medications? (e.g. a detailed, up to date Alert Bracelet or wallet card)

    If you were admitted to a hospital tonight while cognitively impaired, what do you carry on your person that would enable the junior doctor in casualty to more easily access your history?

  4. Prof Jane Andrews says:

    Why are we communicating so badly? A few thoughts:
    Rights of individual privacy over common sense and community costs (which also means we collect little or not outcome data and cannot evaluate value in care)
    Fragmentation of healthcare between state/federal payment systems
    Dr shopping so people can choose who knows what about them
    Fearful attitude of hospital IT departments to using any ICT support over which they cannot drape a firewall (essentially blocking communication with any one outside the hospital concerned)
    Money – as it would cost a lot to fix the problem
    Parochialism, as each state and each hospital wants to have their own solution
    Staff support – why is it an Dr’s job (typically and intern) to chase results? surely this is an admin task?

    I am sure there are other contributory factors, but solving these would be a good start – although I’m not holding my breath…..

  5. Anonymous says:

    This poor communication actually puts many patients at risk. Whether it is at admission, during a hospital stay or at discharge the ability for the acute sector to communicate with the community sector is abysmal and vice versa. Likewise communication between public and private hospitals and also within the private hospital system between different providers. Unfortunately the general public do not understand the risks and happily seek out treatment in a range of different settings. Ideally the GP should be the keeper of the record as the coordinator of care, however many GPs complain of a lack of discharge information. People also go to a variety of GPs based on price and convenience rather than seeking out one practice to hold their record. The biggest risk is the private sector where there are no junior doctors to track down records or clarify co-morbidities or reconcile medications. In an ideal world the patient would hold a full record that they are required to share with all healthcare providers but this is unlikely to ever be achieved. Maybe each patient should be obliged to select a GP practice to hold their full record and with electronic communication information could be released on an as needed basis to other health care providers.

  6. Anonymous Senior Physician says:

    I read James Dando’s article & sympathise with his concerns.
    As a senior physician (semi-retired) I have seen a great deal of change during my career in hospital & community roles…initially in a group family practice,then overseas,& returned to pursue my higher degree as a physician .
    I understand the new generation of doctors who cannot understand why digitalisation of a persons health record is not the answer to the problem.
    In an ideal world each & every one of us should belong to a group practice who maintains a full record on each patient….which is accessible in an emergency situation with the patient ‘s consent. In addition I feel this should be supplemented by each patient having the equivalent of the paediatric “Blue Book” (maroon in Qld) in their possession with details of consults & attendances.
    As others have noted, this is a problem with “doctor shopping” & our mobile society. The current push for a E-record is ,in my opinion, impractical & unworkable. We can have the best of both worlds!

  7. Dr Sarah Smith says:

    I am Australian trained living and working in Canada (rural GP and rural hospital). We have Netcare. It is a province wide online database of a patients pathology, labs, operation reports, consultant letters, imaging , pharmacy collected scripts and the prescribing doctor and hospital discharge summaries. No GP visits. It is a two step process to access the database (username and FOB pin, then username and password). It is audited and they DO fine people and smear their name across college update emails if you are caught looking up someone who is not directly under your care. It is not an opt in or out system, it happens for everyone for every test and the test results are dumped there automatically by the pathology labs, medical records, etc. It is brilliant! Especially rurally and if I send my patient to any hospital or imaging department in the city I can track all the labs and imaging ordered. Saves so much time and I am never going to share my log in details with anyone for fear of public smearing, fines or loss of licence! While it is not perfect it is user friendly, it protects the private GP consultations while allowing the hospital doctor to know who the GP is (if you check who prescribes their meds) so easy to track down. They are developing an ereferral system within netcare that tells you who has the shortest wait time at the moment and what that provider does. Why do we re-invent the wheel, look at other health systems and beg/borrow/copy!! My current wish is that Canada would look across the sea to Australia and borrow their GP electronic medical records software – EMR’s in Canada are like using dinosaurs after 10years of general practice in Australia!! But I guess we all want to invent our own wheels!

  8. Anonymous says:

    Whatever the reasons, this poor communication system has to change immediately. Thank you James for your comment. I hope someone listens to you.

    Junior doctors and many senior doctors are embarrassed by such archaic communication which is no longer used in any other profession. Patients laugh at us when we say we need ‘to fax’ a letter.

    This poor communication has been at least blamed for the death of one patient, as reported in the media because of the delay in information reaching the treating doctors. Letters are sent to the wrong address in the mail and may take weeks to be read. Faxes are never acknowledged as being received, and patients may be mistakenly thinking they are on a waiting list, to find out that the fax was never picked up.

    Faxes as being more private and secure is now a myth. Letters faxed are generated on computers and emailed between professionals before being printed and faxed, using more labour and costs, rather than just emailed. Some are even sent overseas for cheaper typing costs.

    So much paper is being wasted which is painful to see. Fax machines are covered by papers waiting for someone to pick up. In our department, many letters faxed are sitting around the fax machine that takes a third of the space of the doctors little corner. they have been sent to the wrong fax number and are exposing sensitive information. At least, this time the fax number was in the hospital not some business across the road.

    Please, it is long time to move on from generation-Fax and the use of pagers that companies are probably not making them anymore. Our Prime Minister said it is the era to innovate, why not in Medicine?

  9. Anonymous says:

    Having access to comprehensive and easily accessible records such as e-records can be a godsend for patient care especially in an emergency, but it is important NEVER to blindly assume that the information is complete, correct or up to date.

    The use of electronic templates (eg for operation reports) makes it very easy for incorrect information to accidentally become part of the patient’s permanent record; patients obtain treatment in ways that deliberately keeps information off their record; e-records can become just as unwieldy as paper records if key information is not flagged so as to be accessible, but diagnoses change, social and employment circumstances change, and exactly which information is considered relevant to flag may change over time, and time pressures in most consultations work against updating any information which is not perceived as directly relevant to the problem at hand. Relying on outdated or incorrect information can be as as hazardous as having no information – I have seen this happen in practice.

  10. Dr Wendy Muircroft says:

    Thank you for highlighting the significant issue of continuity of medical information.

    I graduated over 20 year ago, and the tasks that are described are unchanged from that time, yet some hospitals have very sophisticated electronic medical records. Is it possible to access all clinical information about a patient from these records? Simple answer is no. Some of the ones I’ve seen work well whilst a patient is an inpatient, and all of the records follow in chronological order until the date of discharge.

    Yet at times the patient’s outpatient correspondence can often not be found. For some of the EMRs there is no obvious filing system to look up the records. For instance, some EMRs have an index page where you can look up radiology and pathology results and subspecialty correspondence as each has a tab that you can click onto. Other, less optimal EMRs, have all correspondence filed in the chronological order that it was received at the hospital. It may not be identified by the author or specialty where it came, and buried in the EMR under the name of the admin assistant who scanned it into the file, so the letter is not identified as a clinical entity on the EMR.

    To add to this information access problem, within the same city, hospitals that have the same system may not have access to patient records due to privacy and login issues. Further, within a hospital, different specialties may have their own operating EMR that all other hospital users do not have access to. Different health identification numbers for patients further complicate this problem.

    Cross health board EMRs can work. In Auckland in New Zealand, it is possible to do outpatient subspecialty clinics in 3 health boards and access information about patients from those 3 health boards from a single desktop. This is aided by each patient having a unique national health identifier number, which their health providers use wherever they are in the country.

    Therefore it is possible to eliminate some of the obstacles in obtaining patient information, but health boards choose not to do so and install white elephant vastly inefficient operating systems that wouldn’t be used in banking or other industries. I think that gaining information about patients for each consultation takes much more time than it used to when we used paper files, and it also takes more time to make a computer entry documenting the consultation. Using clinical time to do admin jobs seems to be an expendable asset and is vastly expensive. I wonder what it will take to improve systems communication?

  11. Travis. says:

    A huge point of news the medical profession very purposefully pushes under the carpet and seems to refuse to even talk about becomes very relevant here. I speak of Edward Snowden’s releases published by media. These include minutes of a meeting where Australia offered to share all of its citizens medical records to the other 4 countries comprising the ‘Five Eyes’ and even clarified that they didn’t see any reason these documents should be classified for national security purposes only, they were fine with those countries using the information as they wished. They did not use the term Medicare data, or even data, or metadata…no they offered medical records.
    Now despite my attempts to make this a discussion point amongst doctors, no one seems willing to even begin discussing it. Did our Colleges or Unions or other representative bodies take up the issue with govt? Not to my knowledge.
    So when we’re given evidence that our patients records have been illegally obtained and are now being offered to others illegally for purposes not in the interests of our patients, and keeping in mind many of us swore oaths to protect and uphold the privacy and autonomy of our patients and to even refuse governments and laws at the risk of punishment to ourselves to uphold our patients interests foremost, we ran and hid and are still hiding.
    I would assert we bought ourselves an express ticket to the back of the line in claiming any right to offer decisions on our patients privacy. We have been a demonstrable pathetic lack of force against this injustice to our patients. We are no longer to be trusted when it comes to standing up for our patients in the face of government.
    Unless we realise our folly and take up the fight for our patients against the biggest breach and misuse of our patent records in history, then I think our only genuine input on patient records is the patients should be deciding this one, we lost our right to have our opinions listened to.

  12. Anonymous says:

    A poorly thought out and ignorant view of someone who has only worked in the healthcare system for three months. What do you propose we do with all the notes from pre computer or pre EMR presentations? Should we force all hospitals and GP clinics to use compatible software regardless of their budgets or needs? Should we force patients to forego their rights to privacy or even anonymity if it is required?

    What right do you have to find out that a woman has been physically abused in the past if she turns up to a different hospital with a cough or some chest pain?

    Bear in mind when you berate a system that it is a system the whole country uses so to change it isn’t a simple matter. Your concerns are valid, your thoughts aren’t original but your view is ignorant.

  13. Anonymous says:

    A billion dollars for patient-controlled charts. I don’t know about Face Book. If there is an area of a Face Book page where stuff can only be accessed with a password, then FB could do our patient-controlled medical records for free.

    Just pay me 10% of what my idea can save the taxpayers of Australia. That’s all I ask.

  14. Andrew Nielsen says:

    To the person who said that the writer is ignorant, their only sin was stating what we already know is true. But there are things that could be done to streamline the process. Making medical records contactable by a standardised email address than can be inferred/remembered from the name of the hospital would be a good starting point. Much faster than standing in front of a fax machine hoping each fax goes through.

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