One Hundred Foot View
Monday brought another milestone in my young career as a physician: it was the first day in my Adult Neurology continuity clinic in which I was revisited by patients I had seen previously in the same clinic. As a Medicine preliminary intern, I did not have the opportunity to have a continuity clinic. Accordingly, I am just beginning to learn the dynamics of the clinic and the triumphs and travails as someone’s outpatient Neurologist. I have ordered a variety of tests. I have prescribed a number of medications. I have ordered some unknowable number of soft cervical collars. And I have even admitted a patient from clinic due to concerns about a medical emergency requiring expedited inquiry and management. I now have my own “patient panel,” and I am tasked with monitoring their movements into and out of the clinic and associated medical settings (scheduling) and managing their health. Given that I have only two half-hour followup slots every two to four weeks, my continuity clinic has rapidly filled to the brim with patients I initially met in the clinic or in the hospital on the Neurology inpatient service. My schedule is filled for returning patients through May 2012. And thus, I have to adapt and decide when I see each patient: Does this patient need to return to my clinic, or can I monitor her progress through other means of communication (email, telephone, etc.)? If the latter, how can I best manage all of the information regarding the patients caught in the grey zone without a fixed followup plan? Should I stay in touch with my patients by email which transcends all time boundaries, or should I limit communication to the telephone which is faster but bound by social convention to certain hours of day and night?
Managing information is an incredibly important skill for physicians at all levels of training. For example, the overwhelmed intern needs to learn how to manage the information overload that arrives in the form of vital signs, lab values, physical examinations, plans discussed on resident and attending rounds, and consultant recommendations. When managing ten or more patients, it is essential to develop a means of organizing, triaging, and prioritizing data points and tasks. For me, as a newcomer to the Neurology clinic, I need to figure out how to keep track of my patients, determine when to bring them back to clinic, manage long medication tapers, solicit the advice of experts when there is little evidence to guide therapy, schedule emails and phone calls for updates, and develop information management tools for my patients to help them organize their own self-care. Recording all of this on paper would be a logistical disaster and would not be portable. I initially started with a password-protected text document that unfortunately could not effectively layer or link information. I have finally started using a database program, Bento, to help organize my patients, each with their own dossier containing information regarding their last visit date, their next visit, their diagnoses, a brief summary of their cases, and a checklist of items to follow and monitor. So far, it has offered me a quick, easy, and secure method of recording and accessing information on my patients separate from the hospital electronic medical record. With any luck, this will help me maintain a visual on the grand overview of my clinic and prevent the dreaded “lost to followup.”
I don’t see the point of this. Isn’t this what an electronic medical record is for? How is your Bento database going to help if you’re off sick, away, move on, etc., and someone else has to manage that patient’s prednisone taper? I would argue that one should focus on better utilizing the EMR and tailor it to meet your needs, rather than maintaining some sort of shadow chart. In part, this ensures you’re not working in some sort of bubble separate from your other physician colleagues who may be taking care of the patient as well. Furthermore, do you think that your strategy is tenable in the long term in a busy practice? Your point is valid that beyond 10 patients, one needs a more robust system, but when this starts to get into the 100′s, most people would become overwhelmed with maintaining more than one system.
Good questions.
The manifestation of the electronic medical record is highly variable between medical institutions: some have more functionality and some have less. The customizability of EMRs also is IT-department dependent. Several members of my department have attempted to make meaningful changes to the EMR with variable success.
Certainly directive information will be included in official EMR notes: details of a medication taper (e.g. tapering schedule), planned therapies and treatments, impressions and interpretations of a patient’s condition, etc. However, some things don’t really have a place in the EMR. For example, I have periodic calendar reminders for phone calls and emails to send to patients: there’s not much point in adding this information to the EMR except in retrospect (e.g. notes detailing important points of contact). I also have reminders for tasks such as reviewing imaging scans, electrophysiologic testing, and lab tests. Some systems have built-in reminders (including one of the affiliate hospitals where I work), but my primary hospital does not. There also is not a useful place to store information about dynamic patient-physician relationships. For example, some of my patients may not need to followup with me if their testing is normal; however, I do not know this until the test result returns and do not want to fill clinic followup slots with patients who don’t need to see me. In other cases, testing might determine how soon they should followup with me. I unfortunately do not have direct control over my clinic scheduling system (it would make a huge difference if I did!), so I have to find other ways of keeping track of these patients.
As mentioned above, there is great variability in hospital EMR systems. My hospital has an electronic record for outpatient notes which also includes some inpatient notes (admission notes and discharge summaries) and test reports and outpatient ordering, a system for placing inpatient orders, and a system for organizing patients lists (for inpatients only). Strangely, these three systems do not interact and only cross-reference in certain directions but not others. On the other hand, one of the affiliate hospitals where I work has a unified system that combines all of these functions and more.
Your point about scaling is an important one. For now, as a resident, my patient panel is relatively limited and there’s little incentive to overbook my time (there certainly is no financial incentive, and overbooking simply means that I have to run between buildings and not ever eat meals). My patient census currently is at 50 patients after half a year; I will definitely reach the hundreds but not reach the thousand mark during residency. Managing information on thousands of patients with a separate recording system would certainly seem to be a waste of time, but this largely depends on the system in which one works and one’s compulsion for organization. I think in the future I would at least maintain a database of the patients who require more attention and closer management (still maintaining a one hundred foot view whereas other patients might be managed equally well at a ten thousand foot view between appointments). After spending a year having others constantly trying to control my time and conform me to their systems, I find that it makes sense in some cases to develop one’s own systems based on one’s own skill sets. For me, I find information management vital to patient care, and the available systems at my disposable are inadequate for that purpose.