Patient experience is hot right now. Hundreds of companies are talking about how to get it right from architects to technologists to physicians to insurers to pharmaceutical companies to lawmakers.

And boy, is it complicated! Ceatro Group has done patient experience work and I won’t lie – it is challenging. Getting it right with all the moving parts and people and ailments and regulations and emotions is hard. 

Yesterday we looked at a purchasing experience that went wrong. Tomorrow we will talk about how elaborate and complicated the behind the scenes operations are to get these kinds of customer experiences right (and they are complicated!) But before we do that lets look at one more complicated customer experience so we have two to talk about tomorrow. This is the predicament I find myself in right now:

Removing a pacemaker you don’t have and getting back a kidney you never had taken out. 

Three months ago a foot doctor at a world-renowned hospital in Boston, let’s call it Hospital A, ordered an MRI to find a splinter of glass in my toe (no worries, it has been there for 9 months). I waited for his assistant call to tell me when and where I need to show up for this MRI. Instead the doctor called me and asked, “Cynthia, do you have a pacemaker? And do you only have one kidney?” (No and No.) He went on “I don’t think you do but your medical record says that you do and it is blocking the MRI from being ordered.” I assured him I didn’t nor had I ever been close to having either of those two things happening to me.

The doctor promised to do his best to resolve the issue. When the MRI was scheduled so I assumed it was resolved until I got to the MRI suite at Hospital A. I was required to have a special consultation with another doctor before my MRI to confirm my lack of a pacemaker. I made a note in the back of my mind to resolve the pacemaker issue and went on with the MRI.

I forgot about the pacemaker until I got to a new-to-me doctor last week at Hospital A. We were meant to talk about the sliver of glass in my toe but before we got to that he wanted to go over some basic health items. What do you think it was? That’s right: how was my pacemaker and how was I faring with one kidney.

Enough was enough. I needed to resolve this. How hard could it be? I don’t have a pacemaker and I have both kidneys. I would just call the records department and clear it up. Oh, how naive.

The doctor showed me my electronic record on the screen in the exam room. The record looked like I expected (I’ve worked with a few eRecords companies on projects) on the first few screens but as soon as he tried to enter an order for an MRI, the very smart system found the one thing on my record that would prevent an MRI: a pacemaker. It delivered a big, not-to-be-missed pop up to the center of the screen that contained two warnings: pacemaker and one kidney. (I think the kidney thing was just thrown in for good measure because it wasn’t preventing the MRI.)

We called the original MRI-ordering-doctor who had said he would handle it and he explained that he had called IT and called Patient Services but was not able to resolve it. The original doctor who gave me the pacemaker and took out the kidney had to do it. Unfortunately no one knew who that was. This eRecords system is shared across a number of Boston hospitals. It is pretty convenient actually but it also means that this warning would pop up in a lot of the great hospitals across town. And it means that there are lots of possible places that this error had come from.

As we were hanging up he added “If I were you I’d get this resolved because what if you come in here, or any hospital in the city, in an emergent situation and can’t speak for yourself and the pacemaker prevents the emergency room from doing something for you.” Of course I went from “Oh this is silly” to “Holy moly!!!! We need to get this fixed!”

The doctors sent me to the Patient Services team who sent me to the Patient Database team. Though everyone was kind it was clear that the onus falls on my to prove I don’t have a pacemaker and do have two kidneys. They would also like me to be sure another “Cynthia White’s” medical record is not merged with mine and apparently I am the only one who would know that so I have to go line by line through my medical files. Hello October Fun!

Though the eRecords system is shared, a patient has her own record at each hospital group and it feeds into this main records system. The woman at Patient Database listed out, with compassion, the 24 steps I would need to take to remedy this situation.  Clearly I’m not alone in needing a record amendment because she read those 24 steps from a list. It started with requesting all of my records from all contributing hospitals in Boston that I may have seen a doctor at in the last 15 years and ended with the most entertaining step. “24. then the original doctor will determine if your requested amendment to your record is warranted.” You mean, there could be a chance that the doctor may conclude I do have a pacemaker after all? At some point in the conversation with Patient Database I was almost convinced that I do have a pacemaker!

So: Patient Services to Patient Database to Patient Records at Hospital A produced a printed copy of my medical record there. 126 pages which, according to Patient Records, is very small compared to most patients (yay?). I’ve now been through all 126 pages and there is no pacemaker nor a kidney removal.

Next I called Patient Privacy at another world-renowned hospital, Hospital B, to explain the situation to them. And then I called Hospital C as well. It turns out that almost every doctor in Boston is affiliated with one of the major hospitals and records pass into the specific hospital record system and then into the shared record system. I am going to start with these three hospital groups and hope I can unearth the record before moving on to the rest of the hospitals. No need to suck up all of November in this fun too.

I am currently waiting for both sets of records so I can’t yet tell you the end of this patient experience story. What I can tell you is that woman at Patient Privacy in Hospital B took pity on me and searched my record on the phone (which I am sure broke 20 rules but I loved her for it) and she thinks she found something. She thinks she found a dermatologist who gave me the pacemaker and took out my kidney in 2010. (Now that’s a multi-specialty doctor!)

I’ll need to wait for the records and go through them myself and then file an amendment form and then, and then, and then . . .  stay tuned for how this ends.

Tomorrow we will talk about why such complexities exist and how hard it is for them not to exist.


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Ceatro Group is a research and consulting firm that helps organizations understand people better and design and/or improve
customer, employee,and partner experiences and underlying operational processes  in order to get better business results.         +1-617-338-4535