Note: Sorry, folks, the above acronym is not meant to be read as anything other than Health Information Management. This post isn't about sex or Jesus - no physical or spiritual merging involved. But I got your attention, didn't I?

So my friend Rosario told me a story last night over the phone that made my blood boil. She is a South American doctoral student at a U.S. university, and she just had a run-in with our health care system which is, sadly, not the first she's had, but probably the worst thus far. 

A few weeks ago she noticed discharge coming from one of her breasts, and, like any woman would, she went to the nearest health care provider (in her case, the campus health center) to be examined. I think the provider she saw must have been a nurse practitioner or a physician's assistant, and while these are generally highly trained individuals who often perform the bulk of day-to-day consultations in larger medical practices, those employed by campus clinics tend to be less than stellar, at least in my own and many of my friends' experience. I'm not sure how much of Rosario's negative experience was attributable to this particular NP/PA's skill deficiency, but what will become clear as I proceed is the deficiency of communication among the different "points of service" Rosario had to navigate.

The NP/PA (hitherto NP b/c I'm tired of typing NP/PA) dutifully examined her patient, which was a good start, but her next move signaled the beginning of a real runaround for Rosario. 

 "I'll just send this to the lab for testing to rule out cancer..."

This before she even suggested possible causes besides cancer, of which there are many. She cut right to the dreaded C word and, not surprisingly, took Rosario by surprise. The thought had occurred to Rosario, but for it to be practically the first thing out of the NP's mouth was very unsettling.

And that was basically the end of the visit. No further explanation was forthcoming. It was in and out and on to the next patient.

So the sample was  sent to a lab, and Rosario waited the next week and a half for the results, worriedly wondering about them when she wasn't busy preparing for the summer classes she was teaching at the time.

Thankfully, the results were negative for cancer, but of course the test was not covered under Rosario's meager student health insurance. (I should tell you that money is very tight for Rosario and has been since she started school in the U.S. as an undergrad - due to poor currency exchange rates between here and her home country, any financial help her parents might send her wouldn't be much help at all, so she is entirely self-sufficient, and assistantship stipends keep their recipients below poverty level.  I've never known anyone more frugal than Rosario, but it's because she has no choice!)

 The NP had requested that Rosario come to a follow-up appointment, and while one would assume that this would've been a good time to go over possible alternative causes of the discharge, Rosario was instead prescribed a trip to the local hospital, this time for a mammogram. Apparently the NP wanted to be extra sure that there was no cancer before she even suggested any of the other possible - and much more likely - roots of the problem. Again, in and out and on to the next patient. It was as though the NP wanted to put off actually administering any treatment herself until she'd exhausted all means of delegating it to someone else, with no regard for the expense it was imposing on Rosario.

So, off to the hospital, no easy feat since Rosario has no car or driver's license and the hospital is far from campus. She managed to figure out which linked bus routes would get her closest and spent most of her day going to and from, meeting only briefly with the referral physician, who told her he had no idea why the NP had prescribed a mammogram - Rosario is only 27, too young for a mammogram to be an effective enough method of diagnosis. His own explanation for the discharge was much simpler: It's a common problem among women, and while sometimes it can indicate something serious, since Rosario's appeared to have subsided, it was nothing to worry about.

But her bill for the test and referral visit - over $400 - is something for her to worry about.

Yes, it's looking more and more like the NP's lack of competence was a big part of the problem...

 And yet, it's not the worst part, or at least that's what proponents of greatly expanded health information technology and use of electronic  medical records (HIT and EMRs, respectively) have been arguing for some time. True, the crux of medical care is the "points of service" themselves - the hospitals, doctors, specialists, pharmacists, and the myriad technicians associated with all of the above - and the whole system can't function if these moving parts don't work as they're supposed to. But if there is insufficient communication between the provider and the patient, or between two providers, or both (as in Rosario's case), then poor care is made worse, and the efficiency of decent care is impaired. 

 Had the university clinic been connected electronically with the hospital as part of a computer-based health information management (HIM) system, then the NP's request for a mammogram (which she'd have posted within Rosario's EMR) could have been questioned remotely by one of the doctor's nurses on the system-wide data platform, the doctor could have responded that the procedure was unnecessary, this advisement would have appeared within the NP's daily worklist, and the NP could decide on another mode of treatment - sparing Rosario, at the very least, the cost and inconvenience of the referral visit.

As for the bulk of this whole ordeal's expense, even the lab test may have been avoided if this hypothetical system of electonic records had an added level of sophistication - that is, an algorithmic component to ensure that the NP followed a set diagnostic procedure before she ordered anything as costly as a lab test. HMOs and large service providers such as hospitals normally require that their practioners adhere to rigorous checklists to eliminate any diagnoses that might be readily treated for the least amount of money before more expensive diagnostic methods are tried. Following such checklists can be tedious and time-consuming, and practitioners are usually under pressure to do everything as quickly and efficiently as possible, but as most Americans know, keeping health care costs down is more important than ever. Preventing unnecessary medical procedures will go a long way towards both keeping costs down and improving quality of care. Overtreating is, after all, no better for your health than undertreating, and is oftentimes worse (I have enough stories about friends' and relatives' overtreatment to fill another lengthy blog altogether).

 To return to the NP in question, the existence of an electronic procedural component within the (still hypothetical) health info management software could have ensured efficiency, especially if there were an administrative mandate that she actually adhere to the procedure; the mandate could even be enforced by the software itself, preventing her progress down the list if she tried to skip steps. 

 There are plenty of health care providers, especially  small independent clinics, who resist the idea of this sort of digital Big Brother watching everything they do and dictating how they treat patients. But there are also large hospitals that can't imagine getting along without their health info management software and EMR systems. I work for one such hospital. Our "e-chart" platform is far from perfect - nurses sometimes click "complete" on worklist items that aren't yet completed, messages get mis-routed, and doctors sometimes forget to check their worklists regularly. Trust me, when a patient comes in expecting prescriptions that we haven't received because the nurse prematurely "completed" the request, or a computer glitch sent the rx to another pharmacy, we techs reminisce about the days when everything was done over the phone, person-to-person, with no potentially glitchy system to throw things off. But then we remember that with the workload we currently have, there would be no way we could get half as much done if we were always on the phone, something that is true for every lab, clinic, and doctor's office affiliated with the hospital. Besides, doctors and nurses are notoriously difficult to get on the phone. Ack.

 ...I apologize if this got boring long ago. It's harder to argue a point from the technical side of things than the anecdotal, or it's at least less interesting. It can also be difficult to convince health care consumers of the advantages of HIM/HIT by presenting them as advantages for care providers - HMOs, big hospitals, pharmacies, "cutting costs" ... most people have more negative impressions of these than positive. These entities after all represent the money side of things, and it's not nice to think of one's good health as contingent upon how much one can spend. The good news, though, is something I hope I've helped to illustrate by telling Rosario's story and relating a bit of what I've learned about HIM/HIT through experience and through research in my spare time: Good health is not contingent strictly upon how much one can spend. Good health is contingent upon good service providers and upon the synergy of patients' providers with each other, with the patients, and with the massive amount of information constantly zipping and changing and growing.

And, oh yeah - my other point to all this was supposed to be that I've been inspired to get a master's in HIM, and how nice it is to have a possible career in mind after years of drift, especially a career where there's so much potential to improve the lives of other people. Yay! (she says with some restraint, since expansion of HIT is no small feat, and it will be rough going for a while)...

End note: I didn't say much about how communication between patient and provider could be improved - Rosario surely would have been spared a lot of trouble if, for one, her NP were more forthright and attentive, and two, Rosario were more aware of resources available to her (many of them online) that would help her validate both her NP's decisions and the potential costs of procedures ahead of time. But I plan to try and address this stuff in a future post...