Integrated Care

Coming from Marshfield, WI to Buffalo, NY has introduced me to many changes:

1. In Marshfield, basically, the Marshfield Clinic was a place where most patients got ALL their medical care. That meant that if I wanted to know if someone was up-to-date on their vaccines, or had had a pap smear or colonoscopy recently, I had only to look in the same electronic health record I was accessing as I was seeing the patient. In contrast, in Buffalo, a lot of the patients I saw this week had 'blank' medical records in our EHR. This is because they had gotten their previous (and some current) care elsewhere in the city -- with different medical groups. In order to determine what had occurred there, I would have to request medical records from these multiple providers and the documents would arrive by fax and be scanned as image documents into their EHR in my practice.
2. Marshfield: one central healthcare provider in town with all specialties belonging to that practice (the Marshfield Clinic). Buffalo: a doctor almost literally on every street corner, competing medical groups, specialties spin-offs, stand-alone ambulatory surgery centers not affiliated with a major hospital. Care is dispersed, distributed and in my opinion, fragmented.

Commentary: I would argue for integrated care within a system. Sharing medical records seamlessly and allowing open conversations with practitioners treating the same patients would benefit the patient and improve their care. The old phrase "It takes a village to raise a child" seems to apply here. When I hear the term HIPAA (Health Information Portability and Privacy Act), I feel it means that a patients health information (PHI) is portable. Unfortunately, it does not seem that at all. The Privacy part is magnified in practice so large, I think it hinders communication between patients and their doctors and most often, doctors treating the same patient don't communicate with each other -- either in person or through congregating around a common patient chart.

If I were in charge...

Okay, here's my grandiose thinking. The patient should have a medical record in a common platform electronic format that is in their possession. They take it with them to every appointment with any doctor anywhere (now that's portability). The doctor plugs this structured information into an electronic medical record shell to view it. He/she updates it with their contribution -- labs, imaging, examination findings, consult note, whatever. The record returns to the patient, enriched with data and care that supplements (not duplicates, not ignores) what is already present. 

Alternatively, the government hosts a secure patient database that is accessed securely by all providers and with a MyRecord portal for patients. I believe some countries (Iceland?) already do this. Of course, they have a single payer system too. 

We spend an inordinate amount of time and effort to obtain patient records and then they are in a format that cannot be plugged into our EHR software to yield structured, searchable distributed data (labs going with labs, imaging with imaging, etc).

(Sigh!)

Until this happens, I will continue to try to get medical records from elsewhere and enrich my patient's chart. However, I will also try to canvas my patients to get their specialty care with associates in our multi-specialty group practice, if only because we share the EHR and can speak to each other.