When the Healthcare System Works

John D. HalamkaI was recently at a meeting where a colleague described a recent interaction with BIDMC. She had a traumatic injury on a weekend afternoon and suspected a fracture. Rather than visit an emergency department filled with high acuity patients, she visited the BIDMC Urgent Care center, knowing they could do imaging and place a cast if necessary.

The facility is within a few minutes of her home and the parking is free.She was seen within a few minutes and x-rayed. The emergency physician on shift apply a cast, and arranged a followup appointment with a specialty orthopedist at BIDMC, Boston.

The next morning, she received a call from the urgent care center asking if her pain was under control and if she felt any numbness/tingling from the cast (no).  She was also asked if the followup appointment was still convenient. She asked if it could be changed to the BID-Needham location as that was closer to her home (and the parking is free). The appointment was made instantly for the following day. A permanent cast was placed and the orthopedist will care for her until she is fully healed and functional.

The entire care process was documented electronically and available to the patient via smartphone, including the clinician notes.

As I’ve written about several times in the past, this “care traffic control”, directing the patient to right intensity of care, then closing the loop for followup care is the future of medicine.It’s high quality, lower cost, and improves outcomes. The IT systems required to do it are more about workflow and process than the simple capture of records. As we envision the next generation of electronic tools, support for team based care with handoff management and closed loop communication among the stakeholders will be the most important new features.

Here’s a personal example of another way the healthcare system should work. As I mentioned last week, I have an arrhythmia for 15 years, but it has never been captured.  Last week I put an ECG monitor from AliveCor on my phone. Over the weekend, I was able to capture a Lead I tracing of the arrhythmia on my phone, send it electronically to my PCP and Cardiologist, and receive a recommendation for next steps - all within an hour.

Here’s the tracing of the arrhythmia, which has a rate near 160 beats per minute. p waves are present, so it’s an atrial tachycardia, which is benign (as opposed to a ventricular tachycardia which could be life threatening). It could be atrial flutter, but I think that is unlikely because I do not have any underlying heart disease.

Here’s the tracing of my baseline ECG, normal sinus rhythm without any abnormalities.

My cardiologist recommended beta blockers or calcium channel blockers.

My PCP noted that my problem list now has three things on it

1. Glaucoma
2. New onset hypertension
3. Atrial Tachycardia
4. History of Lyme Disease  (now Western blot negative, so it is resolved)
5. Low vitamin D (easily fixed with 2000 units of Vitamin D per day)

Beta blockers will improve the glaucoma, treat the hypertension, and prevent the atrial tachycardia. I’ll see my PCP tomorrow morning and be started on beta blockers.

All of these interactions were done from my smart phone, with telemetry provided by me from a wearable sensor. No phone calls, proprietary equipment, or paper-based records were involved.  I have an electronic record of the entire interaction.

Next steps for me including recording the arrhythmia with the AliveCor device while measuring my blood pressure with the Withings BP cuff. During the tachycardia episodes I am lightheaded, likely due to low blood pressure.

From an IT perspective, I’m reaching out to AliveCor to determine if we can upload the ECGs directly into the BIDMC electronic record, just as we do with blood pressure and scale data with our new app BIDMC@Home.

I look forward to healthcare system that combines electronic tools, patients/families, and navigation by a team captain to all the right resources. It’s not just a dream, it is beginning to happen today.