Ehrmann, Daniel E. MS
One snowy Monday morning, during rounds on the neurology service, I presented Mr. Khalib,* a pleasant 63-year-old Egyptian man with a presumptive diagnosis of glioblastoma. He had been admitted to our service as a transfer from an outside hospital and was seeking a second opinion and treatment plan.
After rounds, my attending physician asked me to procure Mr. Khalib’s outside hospital records in preparation for the next morning’s meeting with the neuro-oncology team. As a third-year medical student, I quickly agreed. “How long could this possibly take?” I asked myself at 11:00 AM.
When I called the health information technology department at the outside hospital where Mr. Khalib had first been evaluated, I was told to fax them an authorization for release of information. That authorization, I learned, would be mailed to the medical records department at another location, and I would receive the records by Thursday.
Unsatisfied with this time frame, I told the clerk about the meeting with the neuro-oncology team the next morning. I was placed on hold. A manager returned to the line and said that they could provide the discharge summary but that it would require a separate authorization form. To retrieve Mr. Khalib’s records from the hematology–oncology and radiation oncology departments as well as his brain biopsy slides from the pathology department in time, I would need to contact those departments directly. So I did.
The clerks with whom I spoke in the hematology-oncology and radiation oncology departments were impatient. They each demanded I submit an additional authorization form but were fairly certain they could get me my documents sometime in the next 24 hours. As their irritation grew with each additional question, I apologized profusely for my burdensome request.
When the clerk in the pathology department answered the phone, I politely explained the situation for the fifth time. To release the slides, she needed a separate authorization form. I asked her when we could expect the slides to arrive. Over the clicking and clacking of her keyboard, she kindly replied, “Your patient’s original slides from last week were sent overnight to a Dr. Miller at [another outside hospital].” I was confused by this and asked if Dr. Miller was a neurologist. I was shocked when she informed me that he was a urologist. After confirming with her that we were discussing Mr. Khalib’s brain tissue slides, I asked hopefully, “Do you have any extra copies of the slides?” “Nope,” she answered.
Shaking my head in disbelief, I called Dr. Miller’s office. I explained the situation to Brenda, the person who answered the phone. She told me that they did not have the slides and suggested I call the pathology department at Dr. Miller’s hospital. When I did, the pathology clerk there could not find the slides in the system, and recommended that I try Dr. Miller’s office again.
When I called Dr. Miller’s office a second time, the staff was at lunch. I tried three more times in the next 30 minutes. When Brenda picked up the phone, she was clearly annoyed. She told me to call the hospital that had sent the slides and double-check that they had, in fact, addressed them to Dr. Miller.
By this time, there were eight phone numbers scribbled on my notepad. The fourth number I tried was the correct number for the first hospital’s pathology department. The clerk there, originally pleasant, began to sound irritated as we discussed the situation. I could almost hear her rolling her eyes as she gave me a tracking number and directed me to call the shipping company.
After navigating the shipping company’s endless automated menu, I reached a helpful employee. I explained the situation and provided the tracking number. He quickly determined that the package had been delivered to Dr. Miller’s hospital and gave me the date that somebody in that hospital’s shipping and receiving department signed for it. I started to feel optimistic. “Do you have a record of who signed for the package?” I asked. For a couple of minutes, I heard typing and paper rustling, then the shipping company employee replied, “Well, sir, I can’t find it for some reason.”
So I called the shipping and receiving department at Dr. Miller’s hospital. After a few minutes, I learned that somebody named Mrs. Queen in urology had received the package. That department transferred me to the hospital operator, who transferred me to Mrs. Queen, who told me that she had given the slides to Dr. Miller’s office manager, Brenda.
When I called Brenda again, I related to her the series of people with whom I had spoken and how those conversations led me back to her as the ultimate recipient of the package. She replied, speaking very slowly and sounding as if she were trying to control her anger: “Now listen, son. As a matter of coincidence, my neighbor’s name is Mr. Khalib. If I saw slides with the name Khalib on the package, I would have definitely remembered. Now please stop calling me; I don’t have your slides.”
It was 4 PM. Realizing the slides were gone, I made the long walk down the hall to tell my team the bad news. “I suppose we’ll have to repeat the biopsy,” the attending neurologist muttered. I sat down in disbelief.
Admittedly, Mr. Khalib’s case is an extreme example of the trials and tribulations involved in medical record procurement. However, the medical students and resi dents to whom I have told this story all seem to have had similar experiences. Invariably, when I am recounting my frustration, they respond with apathy toward or not-so-subtle amusement at my dissatisfaction with the lack of care coordination in the health care system.
After reflecting on these conversations, I have come to believe that my colleagues’ reactions (or lack thereof) represent a disturbing state of affairs for those of us just entering the field of medicine as medical students and residents. We are coming into an environment where it is accepted that coordinating the care of transfer patients is going to require us to complete multiple authorization forms and contact outside health information and technology offices, medical records departments, specialty records clerks, physician office managers, hospital operators, and even shipping and receiving staff. “That’s just the way it is,” we tell ourselves.
But why is it that way? Why can’t patient records be shared more effectively and efficiently across institutions? Health sys tems cite privacy, logistical, and finan cial concerns, while electronic medical record (EMR) companies cite proprietary data and lack of government-constructed digital standards.1 Improving private interhealth system communication has not traditionally been a priority for policy makers.1 The problems are complex and involve many competing interests.
And so, as the United States bleeds $750 billion each year in wasteful healthcare spending,2 we routinely, and without question, provide redundant care to many newly admitted patients. As medical students and residents, we do not have time to worry about why Mr. Khalib needs another uncomfortable, risky, and expensive procedure. We cannot help but feel overwhelmed and uninspired by the lack of coordination.
In the process, we have joined the many administrators, politicians, and EMR company executives who are waiting for someone else to solve the problem of care coordination. Not only have we apathetically supported the short-term solutions of our predecessors but we have also actively “kicked the can” down the line just like everyone else. Many new physicians cannot imagine their lives without resident assistants.
In my view, however, those tasked with care coordination have forgotten that many systemic and comprehensive solutions have already been proposed.3 These technologically feasible ideas include developing a universal data language that can be shared across EMR platforms, giving health care consumers full access to their health records at all times, allowing patients to carry a computer chip containing their health data, and creating wiki-style medical records in which each provider adds to the common story rather than starting over and repeating elements.
Thus, medical students and residents need to realize that we do not lack solutions but, rather, the will to insist that technological, financial, legal, political, and logistical barriers must be overcome so that we can provide the coordinated care that our patients deserve. We must come together to demand changes to the system.
Demanding change will not be easy, but it is not hopeless. The collective voice of changing expectations has already inspired some large health care systems to make strides in the right direction, such as allowing patients online access to their medical records.4 As young professionals who are new to the care-coordinating culture, medical students and residents are well positioned to challenge the status quo. Medical student organizations should work with their school administration to publicize these innovative solutions to care coordination challenges. Resident unions should advocate the adoption of novel (and efficient) approaches for obtaining transferred patients’ information. Student and resident groups should work together to recruit community partners and patients who can help us pressure key stakeholders in the private and public sectors to take action. We must not allow ourselves to continue to feel overwhelmed and uninspired. Together, we must work to improve the care coordination system so that patients like Mr. Khalib routinely receive the efficient and appropriate medical care they deserve.
Acknowledgments: The author thanks Dr. John Zeller and Dr. Kirsten Herold for their comments on earlier versions of this commentary.