911 Blogs

There's a blog published by the now online-only Seattle Post-Intelligencer called Seattle 911: A Police Blog. Many cities have similar sites that act as 21st century police scanner bulletins. While surfing for news this morning, I happened to find that the top three stories on the site involved patients I saw at Harborview Medical Center during my last shift. There are also pictures to help understand the injury mechanism. Here's one:

The entries each indicate transport to the hospital where I was on call. My willing compliance with HIPAA and patient confidentiality rules prevents me from saying any more about the specifics of the cases, but I will comment briefly on a facet of patient care that could use improvement. Information is often lost in the transition from witnesses to emergency response personel to emergency physicians to their hospital consultants. (I was a student on the orthopedics team at the time.) We hope that the important information is maintained, but invariably, there is something that we wish we had known at the time.

Even with excellent sign-offs between providers, patients come in to the hospital with limited histories. Patients could be 'out of it' due to shock, pain or pain medicine. There could be a language barrier. Patients are sometimes intubated. Important features may have been observed but not documented on the scene, in transit or during an initial physical exam.

One of the important questions in the patient's history for emergency docs are: How did this occur? Among providers, this question becomes: What was the mechanism? Discovering or confirming this info with the patient is one way emergency providers evaluate patient alertness and orientation while they do their injury surveys, so patients sometimes get annoyed at having to tell the same story over and over again. But that's if the patient can tell the story. Sometimes they cannot.

It turns out that the Seattle 911 blog had information that may have been helpful for providers to understand these patients' injuries. In two of the cases from Friday, the entry was made while (or soon after) the patient was in the emergency department, further underscoring the potential utility of electronic documentation of pictures. One of the patients described the accident in a way that when I saw the image, I thought, "I saw the person involved in that accident." The other image generated a, "So that's how that happened" response in me. The importance of pictures (yes, worth a thousand words) is well known in emergency care; the soon to be history Polaroids of automobile accidents are often taped to critically injured patients' charts. The photo below is more a reminder of how beautiful it was on Friday that how the accident occured.

It wouldn't have changed how we treated these patients to know the specifics documented in the blog entries; the primary determinants of treatment are derived from the physical exam and what the x-rays and CT scans reveal. But one wonders if speedy documentation of accidents and injuries in the field could ever be incorporated into the electronic medical record. iPhone medicine is already being practiced in many emergency departments. The fellow on our service used his Blackberry to photograph one of our patients' wounds. He only partially joked with the radiology tech that he needed it to plan for a surgery. The image was later used to communicate with the attending surgeon and was reshown the next morning during a sign-out conference.

Reforming and universalizing the electronic medical record is central to the Obama plan to reduce health care costs. I hope the software programmers include a mechanism for documenting accident photos. In the mean time, maybe I should keep the local injury blogs open on one of the ER's computers.

Photos are from the Seattle 911 blog and were taken by Ben Otteson and Dana Vander Houwen.

The HIPAA in the Room

I've been a little gun-shy of my posts on Hope for Pandora recently. It seems as though a Seattle medical version of big brother may be watching... watching blogs. One of my friends - a blogging friend and real-life friend - was asked to remove material or shut his blog down because a compliance officer at a hospital where we train was concerned that certain of his posts violated patient confidentiality. Check out Noel's blog, aptly named, Constructive Procrastination.

I have sought to maintain the integrity of my writing by anonymizing my stories or asking permission of my patients to write about them or folding several patients into one pseudo-fictional account in the interest of telling a good story. Each of these techniques fall within the guidelines of the Healthcare Blogger Code of Ethics. What bothers me is that my friend had also observed these behaviors in his writing.

What bothers him is the manner in which he was approached. I'll let him tell the story in his own words, which started a couple of weeks ago. It seems as though our hospital wants to have more control over what gets into the public domain from experiences inside the hospital. Since I have vague aspiration to publish some of my own expereinces in a format more commercial than a blog, this got my ears up. After all, I already write for lunch money over at The Differential. I contacted folks in the community relations department before starting that gig - I wonder if someone else is trying to enforce some element of control or oversight on writers like me.

I think that my hospital administration is a little out of its league right now. One in ten Americans have tried their hand at blogging or something like it. I'm betting that health professionals are no exemption to that. I'm a little worried about an Orwellian move here. Why isn't the Health Care Blogger Code of Ethics or something like it good enough?

The compliance office may be full of friendly faces and good intentions, but do they really know what they are trying to do? Fortunately, my friend has volunteered to provide a voice for us bloggers.

Medical Voice Mail Etiquette

Some of us older* medical students can remember a day without answering machines. If you weren't home or didn't run to the phone in time, whatever the caller on the other end had to say would have to wait. These days, the only reason not to have an answering machine is if you don't have a land line. Furthermore, cell phones record caller identity, the second the incoming message was recorded and the return number. Call me old fashioned, but I still would like you to leave your name, number, time and reason for the call. At least callers still have to wait for the beep...

Leaving a concise phone message is a lost art. This presents a problem for the fledgling medical care provider. What is the best way to communicate with a patient or family member when you have one minute for a message? Leaving a phone message is dangerous territory. On the one hand, you want the patient to know that it is important to call you as soon as possible, but you do not want to unduly alarm them. And leaving a message for a family member can provide more information than the patient would like. I tend to leave overly detailed (read rambling) messages, so am at serious risk for providing too much information. The one minute cutoff some voice mail services enforce in their message recordings is a blessing in disguise. It's a hint that the care provider should leave a short and direct message.

Consider the following situation that happened to me. During the second year of medical school, I volunteered to be a normal healthy subject for a new nasogastric (NG) tube monitoring device. The idea was that an electrical conductance probe just at the lower esophageal sphincter (a muscle that separates the stomach from the esophagus) could better predict gastro-esophageal reflux disease (GERD or heartburn) than other techniques. So this required me to wear an NG tube and a monitoring device for a day. If you know anything about the first two years of medical school, you know that someone with an NG tube will be noticed. I was fine with that - I was getting $200, after all. Anyway, a few weeks after the study, I came home to a message on my answering machine: "Hello this is Dr. NoThink from the GI clinic. We would like you to come in for some more tests. We are really concerned about the results from our study, and think you might have GERD."

Excuse me?!!!?? What went wrong here? Let me count the ways:

1. Delivering a diagnosis this way is like breaking up over the phone. It's just not cool.
2. Coming to a decision about a condition that can lead to cancer based on an untested diagnostic procedure is, well, unscientific.
   
3. Dr. NoThink has no idea who has access to this answering machine. Some options include my medical student roommate, family, my health insurance company. Okay, maybe not the health insurance company...
4. By leaving confidential patient information in an uncontrolled location (including data recordings), Dr. NoThink has broken the law (HIPAA) and opened his hospital to the potential of bad things.

Honestly, Dr. NoThink probably just wasn't thinking. This is a mistake we care providers need to avoid. As such, when making a phone call, here are some tips that can help you comply with HIPAA and avoid embarrassing or ticking off your patient.

1. When you call, expect to leave a message. Be prepared to leave a short and direct statement.
2. Speak in a measured rate and a flat or friendly tone.
   
3. Say your name.
4. Indicate your hospital.
5. Do not say your clinic or specialty. (Unexpected calls from oncology or psychiatry will raise flags for anyone!)
6. Do not leave any information about tests or results.
   
7. Leave your phone number or pager.
8. Ask that the patient contact you as soon as he or she can.
9. Hang up.

If you are ready to leave this information, you can do it for a machine, you can provide it to anyone other than the patient who picks up, and you can introduce yourself to the patient if she or he answers. This seems so straight-forward, it's a wonder that it's so hard to do! As with everything else on the wards, it will take practice. 15 or 20 seconds for this information is my goal. Save the details for a live conversation.

*Interesting... in my most previous post, I argued that I am young for a scientist.

Medical Student's Job

This morning, as I was completing the computer information system orientation for (insert hospital name here), I encountered a stern warning from the chief information officer regarding medical records. Yes, that's really him over there on the left - the web based tutorial was quite well done. He says:

Hospital policy is to respect and support the privacy rights of patients and their families. Only access a patient's chart when it is necessary to do your job.

This begs a question: What is a medical student's job?

You have to grant that this learning module was created for hospital employees, but the 100 medical students and our colleagues from the nursing, PA and pharmacy schools probably compose a sizable contingent of course takers each year. As I see it, our 'job' is to learn. Given that we only see a small number of patients, how do we draw the line between privacy and educational benefit? I am sure this will become clear to me as I am on the wards, so this question is more theoretical than indictment of the system.

For me, learning takes place in the midst of action; reading the chart and following a treatment course is one way of systematizing knowledge.

I imagine that I will only interact with the charts for patients for whom I am providing care. Perhaps there will be incidents when I am invited to participate in a chart review or a didactic involving another chart. That will be the practical resolution of this issue. But what of the theoretical?

What is the job of a medical student?

Transitions

Now that I am transitioning back to my medical training, I expect my blog to veer in the direction of medical topics. Whenever that happens, there are some new rules in play: namely the Health Insurance Portability and Accessibility Act (HIPAA) regulations. This includes a strict reinforcement of the doctor-patient confidentiality agreement. I've been reading other med blogs to see how they appropriately relay experiences on the 'net without compromising patient privacy. The techniques I have observed include:

• Not revealing identifiable information, including date, name, initials, age or ethnicity.
• Substituting identifiable information with false names.
• Idealizing interactions such that no exact incident could be matched with your story.

Since I use my own name in writing, I am faced with the task of balancing the truth of the situation with the rights of patients I interact with. If ever that balance presents itself, I must always push the balance towards patients' rights. After all, it's a physician's privilege to be permitted access to patients most personal issues. Along the same lines, I wish not to write fiction, which what the third bullet above smacks of. I believe that my compromise will be to present only stories vignettes and reflections that are clearly unrecognizable, and saving others for my personal journal.

Any insight about this that fellow medbloggers can offer would be appreciated. Comments or links would be great!

Update:
Dr. Signout responded to this piece with a nice post. Check it out.