Ordering? Authorizing? Supervising? Interpreting?
These are the headers that are attached to orders in our electronic medical record, which have historically let you know who ordered a test, who approved its being ordered, who was the supervising physician for the case -- in the case of trainee cases -- and, in the case of radiology and certain other types of studies, who provided the interpretation for it. Who assigns these roles, and do they mean what we think they mean?
Unexpected Authorization
Just a few days ago I got a stack of faxes from an outside hospital, and included within these were a large number of radiology reports that somehow had my name on them as the authorizing physician.
These were from an emergency department from a hospital outside our system, generated when a number of patients who had sought care there had subsequently been discharged.
(It's true -- I do actually have somewhat of a distant connection to this hospital, because about 30 years ago when I was in medical school, we rotated through this site for our third-year medical student orthopedic rotation, so it's possible they still have me listed somewhere in their system. But more likely, when trying to add the authorizing physician their system, someone queried some database and found my name associated with these patients, so they decided to add my name as the authorizing provider, locate my fax number, and send the reports to me.)
There were reports on several patients who are in fact followed in our clinic, but some on patients I could fine no rhyme or reason for why they thought I was responsible for their ongoing care.
One patient I was able to locate in an insurance database, and there I was listed as having been selected as their primary care provider, although they had never in all these years been seen in our practice. For the most part, however, these were patients who are currently followed by our faculty and residents, as well as two who used to be followed in our practice but had not been seen here in several years. And yet, somehow, I was listed as the authorizing physician for the radiology imaging studies.
Serious Implications
At the moment that each of these patients needed an X-ray or a CT scan or a mammogram at some distant hospital, how was the decision made that it was okay to list me as saying, "Yes, let's go ahead and order this test"?
Being the authorizing provider has some serious implication for test ordering. It implies that you have some overarching responsibility, either as the attending of record for an inpatient service, or the responsible party in the outpatient world. Being the authorizing provider, or the ordering provider, makes you pretty much be the one responsible for following up on the results.
"If you order it, it is yours" has long been a mantra of lab and imaging ordering in medical care. The buck stops here.
These were patients who were being seen in some other location, at another hospital, and while it may have proved useful in the long run for us to get this information, it felt sort of presumptuous for them to put me down as somehow being responsible for both the immediate and long-term follow-up of whatever findings these studies showed.
Recently, there have been some major transformations in our electronic medical record, and some of these assignment links got messed up locally. For example, for a while there our phlebotomy technicians were listed as the ordering provider on all our labs, and the doctors were listed as the authorizing providers. In Radiology, everyone except the radiologists who read the reports disappeared from the documentation on the radiology reports.
In the best of all worlds, assigning the right people to the right roles can actually be really useful, and can make a big difference in the care of patients. Letting all the right people know what's happening, letting everybody know what was found, can help make sure that things don't fall through the cracks. Getting information to the right parties can be an important part of collaboration, and helping everybody know not only what's happened, what the outcomes were, but who's responsible for following up on what.
But none of us like to have this role foisted upon us; no one likes it when someone else orders a whole bunch of tests you didn't want and then leaves the mess for you to clean up.
Benefits of Cooperation
Just as certain features in the electronic medical record have led to frustrations for the team, many of them have dramatically improved care and communication, and helped foster collaboration.
Earlier this month we had a group chat going on between a large group of specialists and subspecialists and primary care providers all involved in the management of a complex patient. One person had found something unexpected and with potentially serious consequences, and they started a conversation, and one by one we all added on people who we thought could provide valuable insights and help guide us to the best course of action.
One by one, people put in their input, made suggestions, took on responsibilities, and, when they were no longer needed, dropped out of the conversation. In the end we were able to expedite exactly the right care for this patient at the right time to get them to the next stages of where they needed to be.
Things like chat groups for urgent appointments, and e-consults where we can formalize the curbside consult that used to take place in the hallways of the hospital, can add significant value while making sure that everyone gets reimbursed appropriately, no one is unduly burdened, and everyone knows the limits of what they are trying to do.
So although we want to see our names attached to things we did order, and we want to be able to see that we were supervising a trainee's case, and we want to know which radiologist read that particular imaging study, none of us want those roles populated in a surprise manner.
And we certainly don't want to have our names added to tests being done at a hospital we haven't set foot in for over three decades, without our express consent and involvement.