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You’ve Detailed Your Last Wishes, and Only Your Care Navigator Knows Them





I greatly appreciated Dr. Daniela Lamas’ perspective in her New York Times article, You’ve Detailed Your Last Wishes, but Doctors May Not See Them. Much ink has already been spilled about the failures of the electronic health record to solve the biggest problems facing patients and health care providers today. This article described a particularly tragic failure: a small piece of absolutely critical information was present in the patient’s record, but it was buried in an ocean of text. Nobody saw it during the chaos of an Emergency Department (ED) admission.

Since then, Dr. Lamas has heard about many other “situations in which last minute ‘saves’ through extreme diligence or chance, such as the one I experienced, had led to a good outcome.” This problem is indeed widespread. A 2016 study in the Journal of Patient Safety estimated that medical errors caused between 210,000 to 440,000 deaths per year in the United States, and that total Preventable Adverse Events due to medical errors occur between 2 to 4 million times per year. It’s a staggering number, accounting for up to one sixth of all deaths in our country last year!

In her article, Dr. Lamas proposed some ideas for fixing this buried information issue. The ideas included:

1. “standards for sharing [...] across all electronic records”
2. “all health systems could require identification of a health care proxy for all patients”
3. “patients should be able to access their health records through a patient-facing interface, send in their own directives, or even update related notes”
4. “all related advance care planning documentation should be in one place in the medical record and accessible with one simple click of the mouse”

Interestingly, three of these wouldn’t help with a situation like this where the information was already present in the record, yet buried out of sight. And the fourth - putting advance care planning documentation in a single place - had already been done at Dr. Lamas’ hospital. The physicians just didn’t use that screen because “habits are hard to break, and without a clear set of incentives, training, and ongoing education, doctors (myself included) continue to record information about end-of-life conversations in progress notes, where they are not readily available”. When the EHR documentation burden is already so heinously high, it’s easy to see how caregivers wouldn’t rush to embrace yet another screen added into the mix. After all, it’s not reasonable to expect the Electronic Health Record to transcend or change its nature, which is, in Dr. Lamas’ words, “a clunky online version of a paper chart”.

She did reference another approach to solve this problem, “clever patient apps that work outside the electronic record”. For an app to help in such a situation, it must not live only with a single person. The patient may be unconscious or may not have their phone with them when they’re admitted. Their health care proxy may not be reachable right away, or perhaps the patient didn’t designate one. So to make absolutely sure that any health care provider who sees the patient can access this information, the app must live with everyone possible who is involved with the patient’s care. The patient, their family members, their health care proxy, each of their physicians, and perhaps most critically of all, their care navigator.

Many of the very sick patients such as the one in Dr. Lamas’ story already have a care navigator assigned to help them navigate through our fragmented health care system and to quarterback the communication among different care teams at different institutions. This person is like the patient’s health care guardian angel. In most cases, they know the patient better than any one physician.

As long as the care navigator finds out immediately when the patient hits the ED and which doctor is seeing them, they can spring into action and make sure the really important information gets to the right person in a timely way. With pMD® Care Navigation™, care navigators can find out instantaneously when the patient is admitted to the ED and have easy access to a concise summary of the truly critical information about the patient’s care plan and decisions.

If care navigators have critical information at their fingertips, are empowered to intervene with exceptional communication software, and find out automatically when patients have their moment of crisis, then we can let the Electronic Health Record go back to doing what it was always designed to do: being the digital filing cabinet. It’s time to move forward to the next generation of software for patients, families, physicians, and especially care navigators.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.


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