As a new doctor, I’ve learned that the best patient care happens as often outside of the hospital as inside. While we treat sick people and get them tuned up, each patient’s opportunity to get better and stay better often depends on their access to resources beyond clinical walls.
One of those resources, I’m learning, could be mobile technology. I’ve seen how a simple text message can help bridge patient care in and out of the hospital and make the medical system a little more efficient.
One of my first patients in the inpatient medicine unit was a what we call a “bounce-back.” He had been in the hospital two or three days before with severe blood clots in his legs. During that first trip to the hospital, his doctor put him on blood thinners to prevent new clots, which can be deadly if they dislodge and get caught in the lungs. His doctor discharged him with a prescription for an anticoagulant that he was supposed to take for 90 days.
He never picked it up.
A few days later, he came back to the hospital with severe breathing problems — the clots had traveled to his lungs. When he was stable, I asked him why he didn’t take the medication his previous doctor prescribed. He told me that when he went to the pharmacy to pick it up, he learned his insurance wouldn’t cover it. He could not afford to pay out of pocket.
I empathized with this patient because he was ill, but I was also frustrated — why didn’t he contact his hospital care team or primary care doctor when he encountered this obstacle? Any of a number of people could have easily prescribed him a different medication.
What went wrong? Could we have done more at the hospital to find out if his prescription was covered? Why is there no simple system doctors can tap into to check this out?
Did my patient fail to take ownership of his health and exercise some personal responsibility, or were those blood clots in his lungs a side effect of a fragmented health care system, where speed bumps (getting a new prescription) become road blocks? Either way, that hospital stay could have been avoided altogether.
My professional obligation is to care for my patients and empower them to improve their health, but I wonder, where does my responsibility end and the patient’s begin?
A few months later, I was preparing to discharge another patient from the hospital, and as part of that, I sent e-prescriptions to his pharmacy, CVS (CVS).
When I returned to his room to say goodbye, I emphasized how important it was to take all the medications that we had recommended. In addition to his other medical conditions, he was also malnourished due to excessive drinking, so I prescribed him some vitamins. Thinking of my patient with blood clots in his lungs, I told him to call me if he had any problems getting his medications.
“My insurance doesn’t cover two of them,” he replied. I was surprised — I had been gone from his room for just a few minutes. I asked him how he knew that and he pulled out his cellphone, showing me two text messages he had received from the pharmacy within seconds of it receiving the prescription.
Armed with this knowledge before my patient left the hospital, there was something I could do. He was trying to beat a snowstorm, so I ran back to the residents’ work room and called the pharmacy. Some insurance companies cover vitamins, but his did not. The pharmacist told me that these vitamins were relatively inexpensive and available over the counter.
My patient’s hospitalization had already cost him a few days of work, so I checked if the over-the-counter cost was OK. He said it was.
At that moment, my mind raced back to my patient with the blood clots. An automated text from his pharmacy could have saved him a lot of trouble, too. His doctors could have used that information to maximize efficiency, reduce his health care costs, and help him take steps forward instead of unnecessary and preventable steps back. We could have solved a little problem before it spiraled into a big one.
About 95 percent of Americans have cellphones, and about 77 percent have smartphones. I work with a lot of patients of limited means — not all of them have cellphones, or even cellphones that receive text messages, but many of them do.
Whether they were about vitamins or vital medications, those text messages gave me a valuable an opportunity to intervene and reflect on what went right instead of lamenting what went wrong. When we talk about where a practitioner’s responsibility ends and a patient’s begins, what something like this teaches me is that it’s not a hard and fast line — it’s a gray zone, but one that we can all work in successfully if we look for opportunity rather than obstacles. For all the apps that help us track our health, it’s profound to me that a simple text message could have prevented a life-threatening condition and a trip back to the hospital.