Opinion | The Goldilocks Dilemma: Too Much, Too Little, Just Right

A few weeks ago, a patient came to see me for follow-up after an emergency room visit that had been necessitated by an incident at their home.

Unfortunately, they were “a bit fuzzy” on the details of what had transpired at home, what had been done in the emergency department, and what the doctors there told them to do on follow-up. They remembered something about their home health aide being worried about them, a couple of nonspecific symptoms, then an ambulance.

There was some time in the local emergency department, and a “whole lot of tests that were done,” although what tests were done was beyond their recollection. They stayed in the hospital for a few days, and then went home, but it was not clear whether any new medicines had been started, or if any of their usual medications had been changed, or even what the final diagnosis was.

Not Much Help From the EMR

So I decided to look in our electronic medical record, and there, among the long list of visit encounters, approximately 10 days before our office visit, in bright red, was something labeled “emergency medicine,” which clearly was a record of that visit to an outside hospital. Clicking on that encounter, as well as in the part of our electronic medical record where we can retrieve outside documentation, I was greeted by a less-than-useful compilation of their hospital stay.

“Encounter details” noted the date and time that they arrived in the emergency department. Social history, “documented as of this encounter” including smoking history, sex assigned at birth, gender identity, sexual orientation, all were noted as being “not on file.” Plan of treatment, once again “documented as of this encounter,” was described in exquisite detail as “not on file.” Same for the visit diagnoses.

One really useful (not) piece of information was something labeled “additional source comments” that told me that if any HIV-related information had been disclosed in this confidential record (none had), then I was not allowed to further disclose it, because this could result in a fine or jail sentence or both. That was it.

There was none of what I assume was a lot of documentation from the triage note at the emergency department, nor were there any records of evaluations by those taking care of the patient in the emergency room or by the admitting team. The encounter record also didn’t include the results from what were probably a whole lot of blood tests, imaging, consultations, and interventions. No notation about any treatments provided, change in medication, or any follow-up that was necessary. So overall, it was not a very useful transfer of electronic medical information from one site of care to another.

An Embarrassment of Riches

Now let’s take a look at a different case, a patient who recently established care in our practice, who in advance of their appointment had their complete medical records shipped to us. What arrived in three large boxes were several enormous stacks of photocopied medical records and electronic dumps of data from multiple EMRs at other institutions. These were records dating back many years, including old handwritten office notes, scrawled and illegible, as is often the case with us doctors.

It reminded me of that scene in the 1947 movie “Miracle on 34th Street,” when the lawyer is trying to establish that Kris Kringle is, in fact, the one and only Santa Claus by getting the post office to bring in letters that children have written to Santa. The initial letter, while interesting, was not sufficient to convince the judge — hence the parade of court officers who brought in sack after sack of letters from the New York City main post office addressed to Santa.

In our case, we were suddenly faced with an enormous amount of information about a patient we had not even met yet. Was all this stuff suddenly our responsibility? What do we do if the patient didn’t show up for their appointment? What if, buried somewhere within this mess, there was a nugget of useful clinical information, a critical test result that needed timely follow-up? Somehow having this pile of data dumped on us made us feel responsible, like we have to read everything and manage to summarize it all.

The usual response is to just give it to our own medical records department for them to scan into the patient’s chart, so that when the patient then moves on to another place, we can dump it out and forward it to the next healthcare location. Scrolling through some of these pages, we were able to find a relatively recent medication list and some notation about prior medical history and surgeries, but we were unlikely to ever see the forest for the trees.

Quite often in the modern age of electronic medical records, having an electronic connection between disparate systems proves incredibly useful, and you can get what you really need to take excellent care of patients. We’ve all been in this situation where a patient says, “I had some test done at some place, and they told me they were going to send you the records,” but instead we find it in that shared electronic transmission where stuff frequently passes back and forth.

The Right Stuff, All in One Place

I know there are lots of significant issues centered around getting all of these different systems to communicate with each other and around finding common electronic standards, so that a person’s CT scan results can be compared to the previous scan done at another site, or that the creatinine measurement at one institution can be compared to the creatinine measurement at another. But it feels like all of this information in healthcare is important enough that we should more quickly find a way to standardize all of this stuff and put it all in one place, so a vaccine in one city is the same as a vaccine in another, and medication prescribed here shows up everywhere that a patient goes.

But for now, the first patient is going to have to sign an old-fashioned “paper release of medical information” form, which we will then fax over to this outside hospital, and hope that someone mails their actual medical records to us, or maybe, if we’re lucky, e-faxes it. For the second patient I described, we’re probably just going to look through the most recent stuff, keep our fingers crossed, hope for the best, and scan it all into our chart, and then everyone will know it’s available to look at if they find the need. Maybe someday soon we’ll be able to have those scanned pages synthesized and summarized by a smarter system using optical character recognition and artificial intelligence to create an accurate history of what’s really going on in those 40 inches of copied medical history.

Every once in a while, we get it right — a really great discharge summary from another hospital, an accurate medication list, a detailed and well thought-out plan, a 1:1 matching transmission of data from one place to another — that allows us to seamlessly take excellent care of our patients. Hopefully, we can continue to move towards this idealized world, making our lives and the lives of our patients better.

Not too hot, not too cold, but just right.

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