“They told me I had to get the information myself,” she said.
“What? Why?” I responded, annoyed.
“They said it wasn’t in their computer, and that I’d have to get it myself. They said since you’re a doctor here, you could easily check the computer yourself and get it from medical records,” my wife continued.
“That’s crazy! I’m not allowed to look at the computer records; I could lose my job! And it’s much easier for them to get the paper records than me! ” I was incensed.
“What do you mean? Can’t you just go pick it up from medical records? The nurse said it would be easy,” she continued. “Why are you so upset?”
A Learning Opportunity
I felt myself being sucked into a Kafka-esque bureaucratic nightmare, medical-style. Unfortunately, my premonitions were on the mark – I was going to invest a lot of time, spend some money, and endure significant aggravation in getting the medical records on my son that they had failed to get. The worst part was THIS WAS MY OWN HOSPITAL where I had worked for the past 8 years, the last 3 as a section chief. I never ask for special treatment, and I was not going to get any special treatment — which meant I was going wrestle with The System like anyone else.
It’s often said that the problems with medical errors are “system issues” not “people issues”. I would suggest they are both. A good system, with irresponsible people, doesn’t work. And good people in a bad system preventing their best effort drives out competence. I’ll keep track of both.
I tried to approach this as a learning opportunity. As some smart person once said, “’Experience’ is what you get when you don’t get what you want.”
Getting Experience (Instead of what you really want…)
Our twins attend the ChicagoVirtualCharterSchool( http://www.k12.com/cvcs/ ), which is part of the Chicago Public School System. They require proof of vaccinations. Getting such proof would seem trivial given that our twins were born in the hospital where I work, our pediatrician is in that hospital, and we have an electronic medical record (EMR). It was far from trivial.
After checking the electronic medical record for vaccination proof, the nurse tells my wife that although everything else is there, including for the other twin, there is one vaccination – the first one — for tuberculosis (TB) that’s missing.
This would be a system issue(#1). Somehow, the information about the vaccination, which was very likely done for both twins, wasn’t entered in the computer. Seems like the right solution is for the doctor’s office to check to medical record, right? Afterall, they have access and permission to do so – AND I DON’T. Let me clarify this point. I don’t actually have permission to access my family’s medical records, even though I have access to the EMR. In fact, I CAN BE DISMISSED FROM MY JOB FOR LOOKING AT THE MEDICAL RECORDS FOR MY FAMILY, INCLUDING MY OWN. Absolutely, no doubt, on the books, not to be ignored, rule. No exceptions.
Down the Rabbit Hole
The nurse said, “You have to go check the medical record yourself. It should be easy since your husband is a physician and can look it up in the computer himself. Or you can fill out a form to get the records.” Basically, the nurse was telling my wife to have me do something illegal by looking in the computer. Plus, we were just told they didn’t find it in the records; as a geriatrician, it was unlikely I would have more luck finding the pediatric vaccination records. Further, there was no need for me to fill out any “permission” forms – this wasn’t an “outside hospital”, it was my own institution! The doctor just needed to request the records be retrieved. Of course, my wife has no idea this is true, since it seems reasonable enough to ask me to look it up.
So the nurse either: 1) doesn’t know the rules or 2) she does know and doesn’t want to put in the effort to get the medical record. I suspect both. One reason she wouldn’t want to do this – it’s a terrible pain to get anything from medical records, and she didn’t want to do that. Why it’s going to be any less painful for my wife is unclear. This is a “person issue” (#1) – someone not interested in patient satisfaction.
I explained this to my wife – I certainly wasn’t allowed to check the computer myself; I could be fired for doing so; the doctor’s office has free access to the medical record; we would have to request the paper record and probably pay for it. The nurse chose to defer that responsibility from the doctor to us. That was the path of least resistance.
And we were under a time constraint. Our son would be kicked out of school without his vaccination record, as the regular phone calls made clear. As we soon discovered, medical records will only promise to make the medical record available in 14 days – after the school’s deadline. The alternative was to have him get another vaccination, a major inconvenience for us, in multiple time and money-wasting ways, and painful and mildly risky for him. Given that none of this was really due to anything we had done, that it would likely be completely superfluous, and it might interfere with his education (a bit), the indifference shown was impressive.
First, we tried calling the doctor’s office to get the records themselves. A pleasant woman put my wife on hold for 10 minutes, discussed the situation briefly, and promised to call back with a solution “right away”. She did call back — many hours later, on a cell phone and in her car. We were unable to decipher her message in the garble, except for a vague promise to call back. She never did.
This would seem to be a “person issue” (#2) for sheer indifference. It was the job of the person who called us to resolve and situation and return out call. She didn’t do that. Perhaps she doesn’t have the resources. But, since I have my own clinic, I would never do this, so my sympathy for her constraints is limited.
Next, we started working with medical records directly. Keeping in mind that I’m a physician who has worked in the system for many years, I have little idea how patients would deal with this issue. I contacted medical records, and I was told the timeline, that there was a form to complete and a fee to pay. Form was filled out and faxed back, followed up with a phone call to confirm its arrival. Promise made to call when it was available. The deadline we had from the school was given, although that did not even get a “we’ll try” comment.
One especially annoying comment on the form says, in essence, that you will be charged about $75 for the records and that the fee is waived for your physician. That really infuriated my wife, having received official confirmed that this was a service provided to our doctor but deferred to us. This is a “system issue” (#2) — a reversal of promoting patient satisfaction by pointing out that you are unnecessarily paying for a service.
As the deadline for school approached, I started calling medical records daily to check on the records. What was especially frustrating was the knowledge that the records were in the hospital basement, almost directly down the elevator from my office, but nobody would help copy them any sooner than the deadline. Fortunately, we were able to get a delay on the school deadline for a week. Medical records called, reiterated the fact that we had to pay for the records, and said I could come anytime to “pick them up”. This is a system issue, no flexibility for extenuating circumstance, (#3) and a person issue(#3) for unwillingness to make an effort.
A Trip to Medical Records
I pessimistically decided I would need a least half an hour in medical records, so I took my only available time, my lunch hour, to make the trip. I carefully brought a check with the exact amount on it. Again, I felt sorry for patients and their families, who assume that “pick them up” means they are going to be ready and come on a tight schedule (and are paying for parking by the hour or are tied to a bus/train schedule). After a long walk through poorly marked grey concrete corridors, I finally found the medical records office in the basement of the hospital. I was startled to be hit with a stiff breeze from a large fan as I entered, given it was December in Chicago. The person sitting up front, who seemed surprised to see me, motioned me to a different person in the back of the room to help.
That person asked, “Who are you?” (no “hello” or “how can I help”) – thankfully I had brought my hospital ID – and then, “Do you have your check?”. She pointed out that, since I didn’t need to have the records mailed, the $5 “mailing fee” was waived. Since I had already written in the amount I was told, I offered to donate the extra funds. She seemed surprised and annoyed. Told me to “take a seat” on the plastic chairs in the office, with no indication of how much longer it was going to take or what needed to be done. Again, wondering why more time was needed, since the records were presumably ready for “pick up” when they called, I sat down and observed the rest of the process.
My pessimistic guess was right on — it took about 30 more minutes for the records to be produced. I honestly have no idea what was happening during these 30 minutes. Nobody ever told me anything. At some point, the person “helping me”, simply got up and left the area without explanation – I actually wondered if she had simply gone to lunch, but decided not to ask. Several people came and went, picking things up, and going about their business. I was about to ask if should come back later (I had a lot to do), when the woman finally walked up, handed me an envelope full of papers, and walked away without comment or explanation. I opened the envelope to check that the papers looked like what I wanted.
As a left, I turned the wrong way walking about the office in the ubiquitous grey concrete hallways – one of the people from the office smiled and laughed as they pointed the right direction out to me. It was one of the few comments anyone offered. Person issue for simple pettiness. (#4)
One thing about medical records: they are full of useless information. I went through the surprisingly large number of papers and found the vaccination record. It was a little difficult to decipher, but I found where, indeed, the vaccination was given. Thankfully, my son wouldn’t need an extra trip to the doctor’s office for a shot, reminding me of yet another “system issue” (#4) – from the doctor’s office perspective, it would have been best if he did need another shot, since they could bill for the visit and we had good insurance. All of this unnecessary time, money, and effort was a consequence of someone’s failure to enter this relevant information in the computer record to begin with.
Lessons learned – Systems and People
1. There are definitely “systems issues” regarding medical information. Those working in the system need better incentives to provide good care. The system needs greater redundancy to avoid this waste of time and energy. The system also needs a better way to deal with problems than kicking it out to the patient and his/her family. Financial incentives should reward responsiveness to patients, not reward deferring responsibility back to patients. Those providing the “service” need some sense that their contribution matters.
2. There are definitely “person issues” regarding medical information. Those working in the system need to be nicer and more helpful. The degree of indifference, bordering on antagonism, is breathtaking. All the medical providers, physicians included, should take greater responsibility for those who work for them. The nurse’s erroneous recommendation – that if followed would put my job at jeopardy – was unconscionable. At least as problematic, the physician never participated in the process. We never heard from our pediatrician, who I suspect has no idea what happened.