When EHRs (and Doctors) Don't Communicate With Each Other

Melissa Walton-Shirley, MD


August 23, 2018

It is a pervasive obstacle to the delivery of optimal medical care: unanswered requests for medical records. There is no accountability even though these requests impact continuity of care, drive up the cost of hospitalization, and affect patient safety.

One weekend, I consulted on a dialysis patient with a remote history of coronary artery bypass surgery who had a blood pressure of 70/40 mm Hg.  His only symptom, dizziness, remitted with a 500-mL saline bolus.  His electrocardiogram was abnormal, and predictably, his troponins were elevated. He described an "extensive" cardiovascular evaluation just 8 weeks previously at a university hospital. He asked to be discharged the following morning on the premise that his heart "checked out okay already."

I had immediately requested his records from his prior admission, to no avail. Aside from an echocardiogram, he declined all other tests because in his mind he had completed them just 2 months earlier. There was no more information upon which to base a firm recommendation, so at his insistence, out the door he went. "Good luck," I thought as he rolled down the hallway.  I hoped his prior work-up really had "checked out okay."        

There will be no reckoning for the facility that still holds his health records hostage.  We providers shrug it off, reasoning that medical records departments are understaffed, or the patient's information just couldn't be located.  It is shameful that we are far less tolerant of how long it takes for a restaurant server to arrive at our table than of the length of time required to obtain life-impacting medical information.  Astoundingly, this costly and dangerous break in the chain of communication won't even get a mention in the discharge summary.

But there is a massive undertaking afoot to integrate electronic health records (EHRs) across the country.

Changes Afoot

According to a 2015 data brief from the Office of the National Coordinator for Health Information Technology (ONC), "Approximately 40 percent of hospitals have health IT systems that are capable of making patient data available from external care settings, while 23 percent of organizations can participate in all four major interoperability requirements: finding, sending, receiving, and using patient data within the EHR."[1]

A related article in Health IT Analytics[2] quotes interoperability and exchange portfolio manager Erica Galvez, who said that the "ONC is leading the charge on developing a Nationwide Interoperability Roadmap.[3] In the near-term, the Roadmap focuses on enabling a majority of individuals and providers across the care continuum to send, receive, find and use a common set of clinical information by the end of 2017." But it's 2018, and many of our fax machines are still sitting idle minutes, hours, and days after a records requests. That silence is an indictment of our apathy.  

Movements like the nonprofit SEQUOIA project have been working to promote seamless information sharing since 2009. I spoke to Sequoia CEO Mariann Yeager by phone, and she told me that the project currently connects over 70,000 hospitals and 110 million patients for fees from $6000 to $25,000 per year depending on their annual operating budget. It's a small price to pay considering how redundant, unreimbursed testing prolongs length of stay and affects staffing issues.  When I asked her why it's taking so long for much-needed connectivity, she attributed it to "part of the journey and the way in which health care information is rolled out.  We've just become digitized in the last 5 to 7 years. We already have a very strong footprint in both the acute and ambulatory care settings that will continue to grow over time." 

Despite efforts, there is a geographic variability in project participation. For instance, "Every hospital and physician's office in the state of Indiana is connected," Yeager said, but participation is much less in some of the more Southern states. 

Not Limited to Interhospital Communication

Echocardiography is one of the most helpful yet most abused tests in hospital-based cardiology. It is a test often repeated within a few days to a few months of a prior study. Failing to research previous test results can also significantly prolong time to diagnosis. Checking the patient’s testing history before ordering and communicating with sonographers can decrease redundancy, prevent unnecessary testing, and avoid reimbursement denials.


Interoffice Communication Also Suffers

It once took me 40 minutes to locate an abnormal ECG that drove a referral to my office for new "atrial fibrillation." The patient was in sinus rhythm by exam and repeat ECG.  After spending the entire visit discussing the implications of "paroxysmal atrial fibrillation," I finally got the original ECG and found it had been misinterpreted and was actually sinus rhythm with baseline artifact.

Should There Be Liability?

If a patient suffers a poor outcome because of missing vital information, does the facility who did not respond in a timely fashion incur any liability? Is there fault when connectivity options are becoming widely available? Why does the Joint Commission, which drives regulation for everything from inspections to text messaging, allow understaffing that can result in untimely communication? Why is there no penalty for failure to communicate? Why do we legislate the transfer of patients with EMTALA (Emergency Medical Treatment and Labor Act) but not the transfer of vital information? 

We need a lot of fixes in healthcare today, but perhaps none are so urgent as the need for access to information contained in a patient's medical record. The least we could do is participate in entities that promote continuity of care by making connectivity ubiquitous.  Surely, we owe our patients that much.


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