I would like to acknowledge the role of our PH nurse coordinators and support staff. The care of pulmonary hypertension patients is a challenge. A typical new patient that I see has already been to a cardiologist and at least one other pulmonologist in addition to their primary care doctor. They have had dozens of tests and perhaps been hospitalized a few times.
Intake Process
The process of caring for a PH patient begins with our “intake”. This person is responsible for collecting all the records from all the physicians and hospitals that a patient has visited. These documents often number in the hundreds of pages. They are sorted and scanned into our electronic health record. In parallel with collecting records, my intake team that is led by one of my two nurse coordinators helps to triage how urgently the patient needs to be seen and my authorizations team is ensuring that we have permission from your insurance to see you. For patients that are doing poorly we try and see them within a day or two. More stable patients are usually seen within a week or two. As my schedule is usually booked solid for a couple months in advance, this requires my nurses to create new space (a magical process known as double and triple booking).
Your First Visit
Before the first visit, my team generally has obtained all your old records including recent CT scans and original primary data (not the interpretation of the data but the actual tests themselves). Prior to your first visit, I review the documents and see if there are any critical pieces that we have yet to receive. We make a last minute effort to fill any critical holes by calling imaging centers, hospitals, catheterization laboratories and lab facilities to do our best to have all your data ready for your first visit.
When you walk from the elevators into my office you are greeted by a great team of warm, friendly and efficient front desk staff. They collect your insurance card and ask to take your picture. Why do we take your picture? In a typical week I can see as many as eight to ten new patients with similar problems. I am much better at remembering faces than names. Thus as a means of creating a personal experience for our patients we collect your picture.
Next, my medical assistants will take your vital signs and review your medication list that you have hopefully already entered electronically prior to your visit. From there, you are taken back to an exam room if one is open or shown into the waiting room until an exam room becomes available. At this point, you have yet to see your PH doctor but my team has already spent as many as several hours working to take care of you behind the scenes.
When you finally make your way back to the exam room, the medical assistant will ask you to sit in a chair that is designated for the “patient”. We usually have two chairs in each exam room and one is strategically positioned so that I can sit at my computer and look directly at you. This way I can input any data into the chart and still keep eye contact with you. In the pre-electronic health record era, doctors spent more time looking at patients but now that the federal government has mandated that we use and electronic health record, we have had to make small sacrifices including spending a bit more time with our heads in our computers.
During our first visit, I will take a detailed history (even though I generally have already read about you in detail and have a pretty good understanding of your situation). You would be surprised by the inaccuracies in the medical records. Next, I will examine you and then go over the key results from the data that I have gathered. We often do a six-minute walk test on the first visit and sometimes do breathing tests and a chest X-ray. Then I will put together my impressions about your diagnosis and outline a plan for further diagnostic testing and treatments. I often draw pictures on the white paper that covers the exam table. I am no artist but I have had a lot of practice at drawing pictures of the heart and lungs. I will do my best to answer all of your questions. I write down the plan on a special sheet of paper that has a copy underneath that gets scanned into your chart. This insures that if you forget the plan and lose the sheet of paper we have an exact copy.
Pulmonary Hypertension Nurse Coordinators
My nurse coordinators are often in the exam room for some of your first visit. This allows them to get to know you a bit. They also provide much of the education about salt and fluids and will explain the process of easily communicating with us through our web-based health portal or the old-fashioned telephone.
Once you leave the office, our work has just begun. My authorizations team obtains permission from your insurance for any testing that I have ordered. My nurse coordinators work to obtain authorization for your specialty medications, a process that can take half an hour or several days. At the end of each day in the office, my team meets together to review each patient’s plan and identify key action items.
Just because you left the office does not mean that the work is done. There is often hours of behind the scenes work. My nurse coordinators push through prior authorizations and appeals to ensure that your expensive medications are approved. They call and check up on you and answer those questions that you forgot to ask during your visit.
In between visits, there is also a beehive of activity. When you call and ask for help with disability paperwork or are not feeling well, my nurses do the heavy lifting. They work tirelessly to insure that your care is moving forward.
In short, I have the easy job. My team does the heavy lifting. Hats off to a great team that allows us to deliver great care to our patients.
