Introduction

Welcome to another edition of Portable Practical Pediatrics. I am your host, Dr. Paul Smolen, a board certified pediatrician with, at the time of this recording, 35 years of caring for Children and a whole lot to say. Thanks for joining me today.

I know, you are wondering if it will be worth your time to listen to a pedcast that has such a strange name, More Cooperation/Healthier Kids. Let me assure you that it will be. While the topic today is not disease specific, it is vital that you be made aware of when your child’s healthcare system is falling short. And let me tell you, it’s falling short. Having spent my entire adult life working in healthcare, I know some of the system’s deficiencies which is exactly what we are going to talk about today. My topic today is every bit as important as parents learning about how to manage fever or teaching their infants how to get good nights sleep. Your child’s well being depends on their healthcare system working seamlessly with one purpose… to improve their health. It is my contention that in today’s American healthcare system, there is a lot of room for improvement on this front, as I will explain shortly. Once you understand some of the problems that I am about to describe, you and your child’s pediatricians can work to be part of the solution. We can all work toward that goal. We, as a country, can only get to solutions if we understand the problems and cooperate to put solutions in place. My hope today is to get parents thinking about bettering the health of their kids.  The good news is that all it will take is a little cooperation. You remember cooperation, something your great grandparents did in their day. Let’s dig into this interesting subject today to learn how we can all work to make your child’s healthcare better.

Musical Introduction

What are my frustrations?

I’ve been a practicing pediatrician for 35 years. I know the day-to-day problems that pediatricians have and many of them are imposed on these doctors unwittingly by various bureaucracies. Self inflicted wounds so to speak. Medicine is basically an information gathering and analysis business, with high stakes. When information doesn’t flow properly, wrong decisions are made about children’s health, sometimes with devastating consequences. My 35 years in pediatrics has taught me that the majority of medical diagnosis is found in history. Physical diagnosis, that is the examination of a child, is usually not as important as listening to their symptoms, what doctors call a history.  Physical diagnosis confirms or denies the thought process around the history most times. This is not always true but generally so.  To that end, accurate gathering and dissemination of information is critical. Your child’s healthcare providers can only do good thinking and make good decisions when they are given good information.  It’s that simple.

How does the “System work against the interests of pediatric patients?”

I believe that today’s healthcare system is failing our children in many important ways, as I will explain. An excellent healthcare system facilitates the rapid and accurate moving of information so that all the providers of that care have easy access. Without this easy flow of information, the system doesn’t function well. It is my contentions that our current healthcare system works against the interests of children in some respects by bottling up critical health information. How is information flow impeded in real life you ask? Well, here are the ways that come to my mind but I am sure there are many others.

1. No vaccine database that goes across state borders. Let’s say that your child lives in New Jersey but is visiting their grandmother in Florida and gets a burn or a dirty puncture wound, both tetanus prone injuries, their doctor in Florida really has no idea of the vaccine status your child. It is likely that your child will end up getting a vaccine in this circumstance that they don’t need.
2. Children with complex problems have multiple healthcare providers who more often don’t work together. As a consequence, multiple health records are created on the same child. Each provider is working without knowing what the others are thinking since all the records are not integrated. Think about an ED physician, presented with a child who has cystic fibrosis or rare metabolic disorder. Rather than knowing what this child’s expert consultants have recommended as best care for this child, information that would be in an integrated health record, the ED physician has to use what information the child’s parent knows and guess at what is the best course of action. Not ideal.
3. Computer systems that cannot talk to one another. To me, this is the most outrageous example of non-cooperation there is. Our government just mandated that all records be converted to electronic records, without making sure that these systems could talk to one another. We spent literally billions of dollars trying to improve medical record keeping what we got was a lemon. This fact causes pediatricians to construct a completely new medical record, every time a child moves or changes healthcare systems.  Pediatricians are regularly presented with a new patient who has moved to their state, arrive with a stack of 100 pages of disorganized and mostly irrelevant electronic records for this unfortunate pediatrician to review in their 15 minute allotted time slot. More often than not, relevant information is scattered throughout the 100-page record and is never read.
4. Epidemiological disease based data collection systems that are only state specific, not nationalized.  This is an example of how this can hurt children. It has been known for a long time, since the dark ages when I went to med school, that benzene; an organic solvent that is used widely in industry can cause leukemia to develop in a child who is exposed to it. Of course, like with most carcinogens, there is a time delay between exposure and the cancer developing. Let’s say a child, while living in NC, lived near an industrial facility that handled and on occasion, mishandled benzene.  Let’s also say that this child’s family had no idea that their child was exposed to benzene while they lived in NC. Before the leukemia develops however, this child’s family moves to Nebraska where the leukemia manifests.  Epidemiologists and pediatricians in Nebraska know that benzene exposure is a possible cause of this child’s illness but since they have no information about exposures in NC (that exposure is not in their database), they will never make the link.  Had the leukemia occurred in NC, maybe the link could have been made not only helping this child, but many others who might be being exposed to benzene from this plant. Analysis can only be as good as the information going in so to speak.
5. While this is beginning to change, controlled substance histories are difficult to access, limited in scope, and are again, only state specific. I have been practicing very near the border between North and South Carolina for many years. Each of these states has a separate drug reporting system for controlled substances, neither system talking to one another.  In fact, only 37 states have such reporting systems. No wonder drug seekers have such an easy time getting powerful drugs. The system makes it extremely difficult for providers to monitor what is going on. Limiting the quantity of narcotics any one individual can get from a physician won’t solve the problem of doctor shopping unless a national database is made available and doctors can see all the prescriptions a patient is getting, regardless of where it was written. A little cooperation here could go a long way.

Everything is reactive rather than proactive

What I don’t understand is why the people we pay to set up these very expensive systems don’t see the problems that they have created. Would it be a herculean task for us to set up national databases for vaccines, environmental exposures, and controlled substance prescriptions? Is it too much to ask for all EMR’s to be able to easily exchange vital information that each record contains? It seems to me that all that would be needed is recognition that these things are important and willingness for everyone to cooperate with one another, something that we seem to have lost the ability to do.

It’s predictable that children will move

It’s predictable that some parents will be drug seekers and game the system

It’s predictable that some children will change healthcare systems-Why not

It’s also predicable that some children will have exposures to toxic chemicals or other known substances that will hurt their health and without knowing the entire range of their exposures, epidemiologists will never figure out why they got sick.

How Can We Improve information Gathering and Distribution in Healthcare?

If tomorrow someone made me the guru of child healthcare in the US, here are the things that I would want my new, improved healthcare system to be able to accomplish:

1. I would give pediatricians adequate time to review and gather information about your child’s health. This partly means actually giving them more time to review records before visits and it also means, organizing the information in a very tight, easy to digest fashion, something that many EMR systems fail to do. Just take a look at one of my previous post on this subject to see what I am talking about.

2. I would deemphasize the recording of medical information and increase the gathering of medical information. It’s my opinion that we don’t have the balance right yet.
3. I would make Electronic Medical Records able to talk to one another with easy transference of critical health data such as immunizations, growth data, problem lists, surgeries, and medications being taken. Changing doctors or healthcare systems should make no difference.
4. I would make vaccine databases, with all the children’s shot records, be national not regional or state specific. This would greatly help epidemiologists see trends and problems in our vaccine delivery system.
5. I would make controlled substance prescription information national as well, eliminating the ability of patients to shop doctor-to-doctor and state-to-state for controlled substances. I would make it mandatory and easy for a provider to check this national database before writing one of these prescriptions. This would make it much easier for providers to find and hopefully help drug seekers, regardless of where they are acquiring their drugs.
6. And finally, I would create a database regarding exposures to toxic chemicals, radiation, or other substances that adversely affect the health of children. Again, I would make this a national registry, not done state by state, since some researchers need to be able to identify all exposures regardless of where they occurred.

Why Don’t We Have Cooperation Among Healthcare Providers?

So what are the forces that are holding us back from cooperation and the improvement of our healthcare system for children? Well, here are the factors that came to mind as I pondered this problem:

We are nation of autonomous states and each state needs to have its own laws, identity, and control over its destiny.

We believe strongly in individual freedoms and maybe, somehow, relinquishing personal information about our children to a larger authority just doesn’t feel right.

We also have learned to resist big governmental organizations having any control on us. Many are suspicious of their motives.

Well, I’ve got news for those who resist cooperation, the era of having privacy and control over our personal information is over. The Internet has done that for us. All the more reason we might as well tear down the barriers and cooperate with one another, for the good of our children. Healthcare system… let’s do what’s best for children. Computer engineers, state legislators, healthcare administrators, congress, and public health officials, I have this to say to you; making information flow easier in the healthcare world not only makes economic sense by removing huge barriers and inefficiencies, but it also is what is best for children. Don’t you think that goal we can all agree on?

Outro

I think you can tell, we have a long way to go at improving our healthcare system. In my mind, it’s cooperation that we are lacking. Maybe, along with your child’s pediatrician, you can help do something about that problem. If you enjoy learning about child health with pedcasts, consider taking a moment to like or write a review of the DocSmo Facebook page or podcast at the iTunes store. By doing so you will help others find my podcast. And as always, I would love to hear your comments about my pedcasts. Keep them coming. This is Dr. Paul Smolen, broadcasting from studio 1E, reminding you that there is innovation in cooperation. Until next time.

My thanks to Dr. Monica Miller for her comments and edits of this post. Thanks Monica.