A text lights up my phone late in the evening. It's from someone who is a patient but we've been together for so many years I consider her a friend. She has my phone number from other times she's needed medical advice. She knows me well enough that she can assume I am adept at texting though we've never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn't originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis



There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can't be in a text because that's not HIPAA compliant. It also can't be email because that's not HIPAA compliant. SKYPE? Maybe but I'm not sure how good the encryption is. 

So I sit on my couch and weigh options--all the while thinking, "How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can't be utilized to help my patient or me?" Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it's larger? Will she know how to reduce the size? Yes, I could do what my 1950's MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I'll see tomorrow, needing all the rest I can get. 

What would you do?