Why the Number 313 Gave Me Pause

Three hundred and thirteen.

Turns out, this is kind of an interesting number.

Not only is it the area code of Detroit, Michigan, and some of its surrounding suburbs, but it also has some interesting numerical properties.

Looking it up on the Internet, it’s the 65th prime number, and also something called a twin prime, meaning a number either two above it or two below it (in this case 311) is also a prime number. It is also a palindromic prime number, both in base 10 and in binary (100111001), and something I’ve never heard of before called a “truncatable” prime number, which is a prime number that removing successive digits from produces additional prime numbers all the way down to its terminal digit (313, 31, 1). And — fun fact — 313 was apparently the number on Donald Duck’s license plate.

A Big Sheaf of Papers

But more relevant to today’s column, 313 was the number of pages in the medical record I recently received for a new patient who came to see me several months ago. The patient’s chart was not available through the patient portal, because their previous primary care doctor was not using the same electronic health record (EHR) as our practice, nor was that doctor sharing their records with our system, so I asked the patient to have their prior physician send me a copy of their chart — a routine request for new patients.

When I received this package in the office the other day, I opened it up, and there was a huge sheaf of papers printed out from a different electronic health record system, now suddenly made available to me, for what it’s worth. Be careful what you ask for.

I started flipping through it, and found page after page of mostly useless information, the huge amount of fluff that’s generated with office visits. That included cut-and-pasted information, standard templated formatted notes of office visits for routine annual exams and upper respiratory infections, and an endless series of mandated questions that the patient had answered or that were clicked through by the ancillary staff. Of note, this was a relatively healthy patient, and I didn’t expect to find many surprises.

At one point, however, as I was visually scanning through the pages, something caught my eye: a notification of an abnormal imaging result that looked like it needed some follow-up. This abnormal imaging test was coupled with a recommendation by the radiologist for a follow-up test, which led to a telephone call, and the appropriate test was scheduled. In this particular instance, the follow-up test was normal and the matter was settled — all over the course of 10 or so pages.

Whose Responsibility Is It?

But it made me start to think, what is my responsibility for all of the stuff in here? If I’m receiving it and accepting it into their new chart, don’t I suddenly have ownership of all of this, with all its implications and life/health ramifications for the patient? Sure, the original physician who provided the care is ultimately responsible for follow-up of any abnormalities while the patient was under their care, but I’m now taking this on as my own. By receiving that packet of pages, it is suddenly mine.

What if, buried somewhere inside of there, was something that really mattered? Some worrisome trend, some misinterpreted lab result, some study done at the final visit with their prior physician that noted a potentially worrisome finding and recommended a repeat CT scan in 3 months to ensure this was not something that needed additional attention? Where does our responsibility start and end, and where does the patient’s?

By asking for a copy of their chart, and by virtue of the fact that the other doctor sent it to me, I assume there’s a certain amount of this that does fall on us. Wouldn’t it be great if there was some way to have this massive data dump be not just scanned in as an image that gets stored in the Media section of our EHR — never to be looked at again — but actually turned into something usable? What if we had some system smart enough to read these pages, understand them, and turn them into useful medical information?

Maybe we could get some cohesive synopsis of all those pages, that the patient (and maybe their prior PCP?) can agree is an accurate representation of all those records. It could show years’ worth of lab results as graphic data, outlining trends and suggesting possible diseases, diagnoses, or things that need to be paid attention to. It would catch patterns — for example, recurrent urinary tract infections — or flag potential mental health diagnoses, or something else we might be missing.

Spotting the Needle in the Haystack

These 313 pages were not that much, and while I admit that I did not read every single page and create a synopsis myself, I was able to flip through it, see the things that I thought were of interest, and conclude that there was nothing new I needed to do about this patient’s care moving forward based on these records. But many of our patients have so much more than this. Some have what would be turned into reams and reams of paper if it was printed out — multiple long hospitalizations, years of office visits, and thousands of blood tests, along with imaging reports, other specialized testing, consultations, and diagnoses.

As more patients hop from PCP to PCP and from health system to health system, and notes get longer and longer, will we be able to always spot the needle in the haystack, see the forest for the trees?

Wouldn’t it be great if our data were represented in a way such that someday, if I tried to prescribe a medication for a patient, the system would be smart enough to say, “Hey, Fred, we noted that in 2003 (before they came under your care) this patient received this medication, and while no one labeled it as an allergy, they clearly reported back then that it was ineffective or caused a serious side effect, and therefore they were switched to something else. Maybe you don’t want to try this one for them again right now”?

It would be great if we all kept terrific, up-to-date charts, and if our EHR included an accurate and well-annotated past medical and surgical history, an up-to-date medication list, and a list of true allergies and adverse reactions to medications. Maybe then the EHR would be all that we would need to represent our patient’s health moving forward for anyone picking up the mantle of our care.

Instead, for now, the potential for so much useful information to be buried in the reams and reams of data that are generated by EHRs today just makes me long for a smarter and better system.

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