When I went in for my first-ever screening colonoscopy, I was worried about complications or the doctor finding cancer. The procedure was routine, my results were good and I was back at work the next morning; however, the process was uncoordinated, inefficient and lacked a customer focus. The experience could have been improved with IT solutions common in other industries.
The GI Referral and Initial Office Visit
My first colonoscopy began with a routine visit to my primary care practitioner. When I mentioned that I had not had my recommended colonoscopy after turning 50, she referred me to a gastroenterologist. My PCP uses an electronic health record, but the gastroenterologist to whom she referred me does not. So when I visited the gastrointestinal (GI) practice for my pre-procedure exam, I had to complete all the same paperwork, including a detailed medical history, and I had the same physical exam I had just gone through with my PCP. I also received printed instructions about what I needed to do and what to expect the week of my colonoscopy.
Problems and Re-engineering: I had to remind my PCP that I was two years late for my screening colonoscopy. Ideally, she would have reminded me after receiving an EHR-driven alert that I was over 50 with no colonoscopy in the record. It would be similar to how Amazon.com reminds me about things it thinks I might buy. Electronic self-entry of my history information would have saved time and avoided potential data entry errors. An electronic referral and transfer of my history and physical examination to a GI practice EHR would have saved time and avoided potential errors. A relevant example: When I book a flight through one airline on a "code share" with another airline, the details are seamlessly and automatically transferred to the second airline's system. A patient portal could have provided more details about my procedure and what to expect before and afterward.
Pre-Procedure and Check-In
The gastroenterologist's office called me a couple days before my procedure to move my appointment time up due to a cancellation, but I did not receive an email or other electronic confirmation of the original appointment, or the time change, so I was not sure if I had correctly remembered the appointment time. After the usual preparations at home (see Dave Barry's hilarious description of his colonoscopy), I arrived at my local hospital's ambulatory surgery center. As I got out of the car, I remember wondering what the complication rate was for screening colonoscopies and whether my sister's GI cancer was a genetic risk for me.
The beautifully designed and decorated hospital suggested that its systems must be state of the art. However, my first contact with the hospital -- the check-in process -- proved that false. My wife and I were directed to a waiting room, staffed by two elderly volunteers, where I wrote my name and procedure on a small slip of paper. Later, one of the volunteers carried the slip into a nearby room. My wife suggested this was for privacy purposes, as it eliminated a paper sign-in sheet where anyone could see my name and procedure I was there for.
Problems and Re-engineering: I would have preferred to receive an email or other electronic confirmation of my procedure time and a link to a patient portal where I could research colonoscopy risks and benefits. This could have been automated via an integrated EHR and practice management system. After all, my hotel, my airline and even my bookstore all send me automated electronic order confirmations. Electronic self-check-in would have been more efficient, more private and could have collected information I gave later in the registration room. Even better would have been a quick, automated review of pre-registration information I could have previously entered online. Whenever I book a hotel, I enter my information online in advance, and it's confirmed at the check-in desk.
Registration
Later, my wife and I were directed to a registration room, where we met with a financial counselor and ran into a small problem. My wife had called our insurance company the day before and was told that screening colonoscopies were 100% covered, but the counselor asked for a 10% copayment and the rest of my deductible -- about $800. It turned out the gastroenterologist had written CPT code xxxx5 for a screening colonoscopy with removal of polyps. If he had used code xxxx0 for a screening colonoscopy alone it would have been fully covered. The hospital could not change the code the doctor had submitted but agreed to waive our pre-payment pending a conversation with the doctor's office.
We called the doctor's office while the registration clerk waited. The clerk explained the doctor's standard policy was to submit the higher code in case something needed to be removed during the procedure. If they did not find anything, they would change the code and refund our pre-payment. However, since the hospital had already made an exception and waived our pre-payment, we finished registering and went down the hall to the waiting room.
Sitting in the waiting room we began wondering about the doctor's incentives. No doubt he was paid a lot more for a procedure with polyp removal. Did that mean he would look really hard for something to take out, whether I needed it or not? Since I had only met the gastroenterologist once (for 15 minutes during the pre-procedure exam), I could not imagine how to raise that question with him.
Problems and Re-engineering: The physician has an interest in covering the possibility of finding polyps in my colon, but I have an interest in not making him an interest-free loan of $800. Since most routine screening procedures don't find anything, up-front collection of a large copay is unjustified from a customer service perspective, creates frequent rework to refund the patient's money and change billing codes, and increases the risk of billing errors. In contrast, American Express earns my loyalty with billing and dispute resolution systems that put my interests first and ensure satisfaction with card purchases.
The Waiting Room
As we waited, we tried to find my patient ID number on the electronic status board on the wall. We could not match the ID number on my bracelet with the numbers on the screen. One of the volunteers explained that endoscopies did not have an ID code like those in the tracking system and were not included on the board; only outpatient surgeries were listed.
Problems and Re-engineering: Both from an operating room management and patient information standpoint, it is desirable, and should be relatively easy, to assign ID numbers to
endoscopies and add them to the tracking board. The Department of Motor Vehicles gives me a number when I register a car, motorcycle or other type of vehicle that shows me, on tracking screens throughout the waiting room, how many people are ahead of me.
The Procedure
Finally, I was escorted into an empty procedure room to change into my hospital gown. While I was changing, I counted no less than eight different mobile devices and/or carts -- including a Pyxis drug cabinet, an electronic cautery device and several monitors -- that appeared to be stored in the room. I do not remember much after they wheeled me into the procedure room and started my anesthesia. I woke up in a recovery room and was out of the hospital within half an hour.
Problems and Re-engineering: I couldn't help but contrast my experience at the hospital with other businesses where I've spent a lot of discretionary money. None of the hotels or restaurants I've been to have had me wait in a kitchen closet where the extra equipment was stored, and my health club doesn't have me change clothes in the equipment room.
Follow Up/Results
We did not see the doctor after the procedure. One of the nurses in the recovery area told my wife that they had not found anything to be concerned about, but since that nurse hadn't been in the procedure room, I wasn't sure how accurate that information was. Now, a month after my procedure I still have not heard anything from the gastroenterologist or my PCP about my results.
Problems and Re-engineering: High-revenue customers in other industries get follow-up attention from their vendors. For example, I just received a personal note from the owner of a furniture store where I once bought a chair. A patient portal and email can help with results communication, but technology is not the only answer: physicians and their staff must greatly improve their focus on customer service.
Action Items
My routine colonoscopy experience was uncoordinated, inefficient and lacking from a customer-service perspective. As patients exercise more discretion about their providers, and providers are rewarded for patient loyalty under accountable care, health care organizations must improve the customer service they provide. IT can be an important part of that effort.
Some key steps health care organizations should take include:
- Working with operational leaders to evaluate your organization's ambulatory surgery process from a patient's perspective;
- Emphasizing integration of EHRs for employed and affiliated physicians, especially those who will be part of an accountable care organization;
- Working with outpatient surgery leaders and patients to develop an integrated patient portal including scheduling, personal health record, reference information and two-way communication capabilities;
- Implementing integrated electronic pre-registration and check-in capabilities linked to clinical and business systems; and
- Encouraging and supporting physicians in the use of email communications with patients.