July 19th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network
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There’s a satisfying post on WhiteCoat where he rants against patient-reported allergies. A sample:
When I ask patients about their medical allergies, more often than not patients suffer from at least one. During a recent shift, I had 17 people who told me that they had medication allergies. When someone has an allergy, I always ask what the allergic reaction is. The responses I received included the following:
* Seven people had allergies to various medications (most often penicillin) because their parents told them they had a reaction as a child. They didn’t know what the reaction was, but they have never taken the medication since.
* Four people had nausea and vomiting with medications that typically cause nausea and vomiting as one of their side effects…
He’s right — a lot of people have unwarranted concerns about mild or entirely predictable reactions, and sometimes this can be frustrating on a busy shift. But I also like the commenter who wrote:
I’m not sure how you think the patient is supposed to know which things actually require medical attention, especially when doctors and nurses refuse to give any guidelines over the phone. ‘Come on in, and if you’re aren’t seriously ill, then we can make fun of you on the blog tomorrow.’
Patient perceptions of allergies is a subset of a larger issue facing all of emergency medicine — patient perception of disease. We don’t expect patients to triage themselves, or figure out which symptoms are worrisome and which are benign. That’s our job. I try to look at proper allergy reporting as another opportunity for patient education (my favorite is explaining why someone can’t be allergic to the iodine atom).
More importantly, from the informatics perspective, allergy reporting is a big frustration as well (and one we can actually do something about, ourselves). Patient-reported allergies find their way into every EMR, and trigger the most inane alerts and stops, forever. If a patient reported vomiting once after codeine, every subsequent doctor who sees this patient will have to jump through electronic alert hoops just to order IV morphine. It doesn’t matter if the patient is taking oxycontin and wears three fentanyl patches. The same goes for antibiotics — I think most lay folks would be surprised that we have to wrestle, years later, with the inherited family warning of about penicillin reactions, even when ordering a 4th-generation cephalosporin with essentially no cross-reactivity…
There’s no intelligence built into the system, yet, I think because everyone’s afraid that if a patient has a bad outcome because that 14th medication alert was eliminated, they’d be liable. This line of thinking ignores the notion that bad outcomes are probably happening because there are so many useless alerts, they all tend to be ignored.
Someone told me recently (perhaps it was Dr. Reider?) that non-clinical folks involved in setting up electronic health information exchanges thought that communicated allergies to new providers would be the top priority, and were surprised when physicians considered allergies to be less important than, say, recent EKG’s, imaging, current med lists, and the like.
I wonder if this attitude toward allergy records is because we don’t think most allergies are that serious, because we can most often treat whatever arises… or because we’re overcome with alert fatigue.
Whatever the reason, there’s no doubt in my mind that if we had an intelligent, efficient system to process patient-generated allergy reports, we’d be less frustrated with this information, and more sympathetic to the patient’s concerns.
*This blog post was originally published at Blogborygmi*
July 5th, 2009 by RamonaBatesMD in Better Health Network, News
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As we move towards EMR’s, the ability to know who has looked at the medical record may get more and more people in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story shows the importance of this respect.
Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.
I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.
I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.
The hospital said in November that it fired up to six people for looking at Pressly’s records after a routine patient-privacy audit showed that as many as eight people gained access to them.
It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.
With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….
If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.
My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressly case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.
We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.
Dr Holland had no malicious intent, just curiosity. Be careful.
Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter
3 charged with getting TV anchor’s medical records by Jon Gambrell (no subscription required)
*This blog post was originally published at Suture for a Living*
July 1st, 2009 by KevinMD in Better Health Network, Opinion
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Apparently, there are some legitimate reasons why a patient may lie to their physicians.
A recent article in the Los Angeles Times discusses the phenomenon, which as Dr. Gregory House would aptly summarize as, “Everyone lies.”
In fact, a recent survey suggests that “38% of respondents said they lied about following doctors’ orders and 32% about diet or exercise.”
One interesting reason is that patients are wary disclosing potentially damaging information to health insurance companies. Indeed, when patients apply for individual health insurance, their medical record is pulled up. And since trivial details can cause insurance companies to deny health coverage, patients certainly may have second thoughts about giving an accurate history.
Furthermore, “when processing a claim, the insurance company finds something in a patient’s records that contradicts something the patient said when purchasing the policy, the company can retroactively cancel the policy.”
That’s pretty harsh.
But making medical decisions on inaccurate information has consequences as well, including providing poor patient care.
One suggested option would be to maintain two sets of medical records, one that is shared with the insurance companies, and a private one that is not released to third parties. Some patient advocacy groups even go as far as saying, “If your physician won’t do that, it’s reason enough to leave the physician.”
I currently don’t offer such an option. I wonder how many other practices do.
*This blog post was originally published at KevinMD.com*
June 26th, 2009 by DrWes in Better Health Network
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I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we’re rarely reading most of what we re-create each day.
But we’re sure good at following the rules.
Next.
I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.
Next.
I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.
Next.
I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.
Quality three times over.
Now, multiply that same process for each and every other test I have ordered.
Next.
I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.
Next.
I get e-mails and electronic notifications, and electronic communications, as if I know the difference.
Next.
I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.
Next.
I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in clinical electronic reporting. After all, you never hear the bullet that hits you.
Next.
I go home on call, am paged, and reprimanded by a patient who wonders why I can’t look up their medication list on-line, even though I’m standing in the grocery store.
Next.
Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.
Killing me softly …
… with information overload.
*This blog post was originally published at Dr. Wes*
June 22nd, 2009 by DrRob in Better Health Network
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I have heard a lot of talk about ownership of medical information. Bloggers like e-Patient Dave, and Robin are strong advocates for patient ownership of their information. To be truthful, I get nervous when I hear people saying they own something I have in my possession (and I’ve blogged about this). The charts in my office are mine, right? How can I create something and have it not be mine?
I carried this unease with me into the exam room recently. Thinking about the ownership of medical information, I opened a patient chart. The vital signs were already in, and I started in on the HPI (the patient’s story as to why they are there). I do this by asking questions: When did it start? How long did it last? What did it feel like? What did you take? Did you have other symptoms with this? How bad was it? Have you ever had this before?
Hmmm…. Whose information is this?
Then I went on to the review of systems. We have the patients circle symptoms on a laminated sheet and I discuss what they circled.
“You have some chest pain?”
“Well, it was a sharp pain that happened when I coughed. Is that bad? Could it be my heart?”
We then go into a discussion about chest pain and what to look for.
I put down the information the patient has given me and think a little more. The patient’s information?
Then I get frustrated. The past medical history hasn’t been updated recently, she’s been in the hospital and most of the information about this is not in the chart. The medication list is not accurate. The information about her family, lifestyle, and habits are incomplete and I don’t know when they were last updated. I sigh, then try to fill in the gaps as best as I can by asking her questions without betraying my lack of confidence in our record.
We have a meeting of our IT team after this, and I am thinking about this encounter. We are about to roll out a patient portal where patients will be able to log onto our website securely and fill out patient demographics, request refills, and get appointments.
“What information in the record would the patient be best to be in charge of?” I ask. By being “in charge” I mean that the patients would have actual control of this information and we would read it. I tell them about my experience and frustrations and we make the following list:
- Marital Status
- # Children
- Job/School info
- Home DM monitoring, weight, BP
- Address, phone, e-mail address
- Family history
Then I ask, “What information in the record could the patient contribute directly to?” By this I mean that they would see the information as it is in there and be able to suggest changes or additions, but would not be able to actually change themselves. Here’s what we came up with:
- Smoking, alcohol
- Medication List
- History of visits to other medical providers, consultant names, etc.
- Review of systems prior to visit
- Surgical history
We want to be able to assemble this information so that it is in a format that is readable to us and fits our needs, but the patient would have the ability to take this data information and perhaps download it to organize as they wish.
“So what information should they have access to?” I ask, referring to information they can see, download, and organize as they wish, but not add or subtract to. Here is that list:
- Upcoming tests needed (Colonoscopy, etc)
- Immunizations
- Lab results
- Visit schedule – past and present
- Previous vital signs
- Recommended schedule based on their diseases
- Problem list?
Finally, we discuss what is our own information that the patient only has access to if they request it. This is information that either will give them too much information (our thought process and remote concerns) or even things that we don’t want them to see (suspicions about truthfulness or worse). Here is this list:
- Perhaps the problem list – if it contains things like anxiety, suspected abuse, or private things the patient has told us.
- The HPI often has information that is potentially sensitive. People have to feel free to tell us things, and having that information be back in the face of the patient on the Internet (albeit a secure site) goes a bit too far. Who knows if a family member can access it? What about teens? It’s just too complicated.
- Part of the assessment and plan is often conjecture and reminders to ourselves to pay attention to things in the future. If a person has weight loss, we may keep cancer in the back of our minds. If a person is asking repeatedly for narcotics, we may write down suspicions that bear watching in the future. We have to have a place where we can put things down and know they are for our own eyes only.
The last list is the shortest. Yet the current state of things is that the entire chart falls into the last category. This not only leaves the patient in the dark, it makes it so we have to do a whole lot of unnecessary work that the patient would do much better at (and without costing us a dime).
I think this is the sweet spot. This is the way the medical record should be in the future. It should be a shared venture – not just between PCP and patient, but also including other providers. For care to truly move forward we have to dream about what it could be. Our office now has this as the vision for where we want to head. I know my patients will be thrilled, and I am pretty sure I’ll have a lot less frustration in the exam room.
*This blog post was originally published at Musings of a Distractible Mind*
