I was cleaning out an old file drawer today. Here’s what I found. In 1996 I was ‘medical director’ of ‘Care Center C: Internal Medicine practice’ at University of Colorado Hospital, on 9th avenue. As such, even 27 years (!) ago, I was focused on optimization. In this case, how to document and create a best practice, around handling paper files of patient records, and the associated chaos of receiving faxes and mailed results days or weeks after a patient visit.
As you can see, it was … a nightmare. There was no standard process back then. We tried to standardize, AND EVEN THIS workflow gives me chills today. Some highlights:
- “If dictating!” (most notes were illegibly handwritten)
- Manually clips “labs pending” flag to paper chart (inconsistent process requiring providers to ‘remember to do this’)
- File in “holding area” alphabetically until labs return (unless of course the nurse needed it, or provider, or legal review, or quality review, or telephone call from patient pulled the file). We would have 3-4 staff members walking around the office, searching dozens of locations for an urgently needed single paper chart, instead of other important clinical work.
- X-ray report comes by US Postal Mail to the provider’s office box; lab results are FAXED. Somehow these loose sheets have to be united with the right paper file patient chart. (Yikes!)
- Most results do not accurately have the name of the provider or the resident ordering the test so someone has to look up who ordered the test to deliver to the right person. Mind you, there is only a rudimentary registration system, so one often had to look in paper scheduling notebooks to see which provider saw which patient.
- “Decides method of notifying”; in many cases, usual practice was to tell the patient “hey, don’t worry, if you don’t hear anything, it was normal.” AND NOT NOTIFY AT ALL. It turns out, when we did an internal audit later that year, about 1/3 of all completed test results WERE NEVER DELIVERED BACK TO CLINIC. So then, we would have had to tell patients “don’t worry, if you hear nothing, it was EITHER NORMAL OR WE LOST IT.” Terrible, terrible.
- “Postcard to be sent”, where the provider writes the name BUT NOT THE ADDRESS (because, clerical work) and then the clerk LOOKS UP THE ADDRESS for Mrs. John Smith. No potential error there, right? I would routinely have patients bring back postcards saying “I think you meant this for someone else.” And also postcards READABLE BY ANYONE are going through the mail with test results on them… hmmm.
- There are potentially 9 handoffs in this ‘standard process’ Already much better than what went before (no system at all), but still gives me shivers.
- NOT SHOWN: test results would often take 3-5 days to return from lab, 5-10 days to return from radiology, and our own dictated notes (if not just handwritten) took 7-14 days to return from the transcriptionist, by inter-office courier. We hoped the patient would not call us within 2 weeks of seeing them, because we might have NOTHING ON FILE during that time, in their chart.
Today, by contrast: we order the test in the EHR, it knows who the patient is, who the ordering provider is (resident and supervising faculty), it routes the order to the correct ancillary testing location, the bar code label goes on the specimen, or the radiology is digital, the result is electronically delivered right back to the provider and clinic care team, AND ALSO deliver the result directly to the patient (most results in real-time, as soon as the provider receives it, it is available to the patient online). And then, the provider and team have a standard way of communicating (online or letter) with the patient about the result and next steps. 1-2 handoffs, and much more seamless and rapid process
CMIO’s take? 1996 to 2023 is a long time. I know we have LOTS MORE to do and we are FAR from perfect. We can also be grateful for how far we have come. Do you have moments of gratitude for our collective progress? Let me know.