Welcome to My World: Med Wreck

Part of a series on primary care challenges and their solutions.

Medication reconciliation is something we do every day, in the clinic and in the hospital. It shouldn’t be as hard as it is.

A patient with multiple medical problems returns for a fifteen minute quarterly visit. He saw his cardiologist three weeks ago and was told to double his metoprolol.

There are two ways to catch this change: when the cardiologist’s office note comes in, or as we check the patient in for his visit.

The cardiologist’s office note, generated by one of the leading EMRs, runs seven pages and contains entries about immunizations, fall risk and other quality measures of little relevance in specialty care. On one of the last pages, tucked away in a nondescript paragraph, at the very bottom, waiting for me to find it, is the notation that my patient’s metoprolol dose was doubled.

Primary care doctors like me have exactly zero time scheduled to review the approximately 100 scanned documents that fill our electronic inboxes every day. We steal time from our scheduled patient visits, or work from home at night to sign them off. How long does it take to find the hidden dose change in the cardiology note? How many clicks does it take to change the patient’s medication list in my own EMR?

The second chance we have to catch the dose change is when the medical assistant, who has zero training in pharmacology, checks the patient in for his fifteen minute with his PCP. Medication reconciliation should ideally happen at every visit. So should a number of other things, like asking about ER visits, immunizations, fall risk, smoking, alcohol use, domestic violence and so on. Often, harried MAs ask, “are all your medications the same?”, and the primary care visit rolls on.

When a patient is hospitalized, the Admission History and Physical lists their home medications. Even when I refer a patient to the hospital for admission and send along our medication list, I was told that our biggest hospital has a pharmacy technician sit down with the patient to make up their medication list, ignoring the one I sent along. (We are working on ways to make our transfer documents harder to ignore – something like the gigantic key chains some gas stations use for their rest room keys.)

Next, the hospital changes the patient’s statin to the only one they stock, their proton pump inhibitor to their house brand, their ACE inhibitor or angiotensin receptor blocker to their own formulary alternative, and so on.

When the patient is discharged, sometimes they get told not to take the medicine they’ve been on for years and which is covered by their insurance, but the hospital alternative. Sometimes the discharge medication list has both the original and the substitute, like the patient I saw the other day who had both pravastatin and Lipitor on his list.

In a parallel universe, or perhaps in this one some time in the future, “med wreck” might just be “med rec”:

There will be a new EMR mandate that medical office notes that fill more than one page or screen will be required to have a summary that can be located on top without scrolling. But in the meantime, that is something we could do ourselves right now. When i reread my own notes or those of my colleagues, putting a thumbnail synopsis with medication changes on top could save a lot of time, reduce aggravation and probably avoid some errors.

Once we have interoperability between EMRs, several things will become possible:

Patients’ medication lists will be updated by every provider each patient sees as easily as all my iTunes purchases show up on my iPhone, iPad and, should I choose to ever fire it up again, my MacBook. In the meantime, each primary care prescriber needs to take responsibility for their patients’ medication lists. That needs to be part of our time with the patient, because non-providers can’t be expected to spot every problem in a medication list; they are not trained to do that. When a one month supply of a medication can cost more than a car payment, our attention to medication reconciliation is crucial for society and for the pocketbooks of our patients. It is also a critical safety issue when medication prescribing or monitoring errors occur in the care of 12% of British general practice patients (http://www.gmc-uk.org/about/research/25043.asp) and 56% of Austrian patients with chronic disease and polypharmacy (http://www.ncbi.nlm.nih.gov/pubmed/23132894). I don’t have US statistics, but i have no reason to think patients are any safer here.

Each patient’s Personal Health Record will be updated by all involved providers through their own EMRs, just like I started this post on my favorite word processor on one device and made some changes and corrections on the fly on the other.

Physicians will have seamless access to pharmacy records and we will have even better access to insurance formularies than my present EMR has. My screen tells me if a drug is in the red, yellow or green category, but since the pharmacy’s computer knows what the copay is, mine will naturally know that too.

No EMR or pharmacy computer will allow entering an allergy without a comment on type and severity of the reaction. And allergy lists will be shared. But “allergy: amoxicillin” doesn’t cut it. There is a difference between a mild rash from amoxicillin when you had mono and a life threatening anaphylactic reaction.

I think the technology for what I am fantasizing about is here right now. I don’t know why nobody has introduced it to primary care medicine yet. But, until we have the perfect set of tools, we physicians need to buckle up and take responsibility for “med rec”, because we have the training and experience for it. We need to rely on other team members to free us up by doing things that don’t require our training, like data and order entry.

That will be another topic for “Welcome to my World”.

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23 replies »

  1. What are you talking about “changing the standard”?

    The standards of EHR’s are being supplied by politicians and computer engineers.. Physicians are forced to buy them so they have little choice unless they decline Medicare at which time they become a puzzle piece in the healthcare sector that doesn’t fit.

    Neither of us knows exactly how much the “I quit” factor plays a part, but it is significant enough that it is noticeable. That physician time lost is additive to the time wasted on the EHR.

  2. I don’t know what’s been lost due to the “I quit” factor. My own quess is “not much”, on a few dimensions.

    If the current standard of medical documentation does not serve doctors and nurses and patients, then doctors and nurses will have to change the standard. Then we can address the technical aspects of capturing what’s needed. This will require doctors (especially) and nurses to work together.

  3. I agree Leo. The time for marshmallows is over. Time to bring out the wet noodles.

    Seriously though, we’ve been sold down the river by our societies, AAFP, AMA, ACP etc.

  4. Trieith, my last several colleagues that refused all this EHR garbage were given a choice, use the EHR or face fines and loss of income. They did neither. They quit. I wonder how many doctor/ patients hours have been lost due to the “I quit” factor that needs to be added to the estimated 15% time loss.

  5. Brilliant. But don’t expect much from the medical societies, they are too busy keeping the revolving door running white hot between their self serving and certification schemes. But dont worry, they are “hearing us” and “understand our concerns”. They have written many “strongly worded letters”. They are probably at a covention right now in a “heated debate” where they will be passing a powerful resolution that should be able to withstand being pelted by warm marshmallows…if that is ok with the bosses at CMS. You can catch more flies with warm, sweet marshmallows then you can by blasting agencies that are sucking the life force out of patient care and your profession.

  6. On my phone, I can flip through every picture I have taken in the past 3 years in seconds. The same amount of time it takes to flip from one progress note to the next in an EMR. Shameful.

  7. All medical software is designed for the benefit of the administration. None is designed for those who provide the care.


  8. I appreciate all your thoughtful comments. My goal with this series is to show the nitty, gritty of primary care so we can help keep the healthcare discussions anchored in reality.

  9. Paper will continue to beat EMR until someone in practice designs it to look like paper and function like paper on a computer. Redundant if you ask me.

  10. Hear, Hear! The reason EHRs (and other medical systems) are so bad and do not interoperate is that doctors and hospital CIOs buy them anyway. I have been begging doctors to reassert control of medicine for a very long time now. Maybe the pain will finally spur some action.

  11. This dysfunction harms patients too, not only us. Our patient-agency needs more linkage with patients and political power from them. Because of anti-trust, we have been forced to be too receptive and too tolerant of ideas coming from non-professional politicians and stakeholders from above. This is because we are always solitary voices and do not have good organizations demanding and threatening.

    Doctors and patients can get together and exert political power and leadership–and not violate anti-trust–if our purposes are only to help patients and not to fatten our own pocketbooks. Thus, in this drug reconciliation mess, we need to give the EHR industry and the government deadlines and timelines as to when they are to have this fixed….and a consequence if they do not succeed. Eg we add a surcharge that would be deducted from patient co-payments and/or inform all our patients of this dereliction ( there is nothing sinful in sending an invoice to the CMS. )

    We need a large organization focused on helping the patient and making our agency better…one that has the political testosterone of a giant labor union.

  12. “I think the technology for what I am fantasizing about is here right now.”

    It is. It is just being ignored, just like interoperability is being ignored. There is 1 patient. There should be 1 med list. It should be auto reconciled. Why are we wasting time on managing 6 or 7 med lists, most of them wrong? CMS set up this dangerous and inefficient scenario by ignoring interoperability and patient data ownership. Now physicians have to clean up their mess. Once again, paper bests the EMR. It is embarrassing. But don’t worry about us CMS/ONC, just keep making sure you corporate buddies keep getting their pockets lined. I’m sure we will get around to a system that serves patients some day. Until then, keep counting medical errors and blaming us for that too.

  13. Are we treating the chart or the patient? I don’t think it’s ever going to be possible to chart completely and effectively without neglecting the patient. Some people are on too many meds that are being changed too frequently. Why should the precise doses have to be documented in the patient’s history anyway? Until practicing physician’s have substantive say-so in these regulations, regulations such as needing to reconcile the meds will be mandated and patients will suffer. http://www.fixthebus.com

  14. > Med reconciliation is all part of the clerical nightmare that has been
    > placed upon physicians by politicians and business managers.

    So but for politicians and business managers, doctors would not work to understand exactly what meds their patients are taking, how much, how often, and why? Really?

    Then good for politicians and business managers.

  15. You know I just watched electronic hell records today. It goes with this post perfectly. Dr. Is sorry has a great sense of humor. Looking forward to the next installment of welcome to my world.

  16. What you are describing is the French system. Everyone has a “carte vitale” and every provider/pharmacy/hospital has a card reader. All your info is stored/updated each time you use the card. Very nice system developed in the USA. We don’t use it here as it would impede capitalistic EMR companies. Never mind what it might do for patient care. The special interests won’t allow this sort of national healthcare like system.

  17. Med reconciliation is all part of the clerical nightmare that has been placed upon physicians by politicians and business managers. I think that the history of all of this is suppressed and intentionally forgotten. Many were not around when it happened in its original form. The long and irrelevant speciality care notes are in the chart because of a political initiative to “catch” physicians perpetrating fraud. Covering all of the mandated bullet points “protects” physicians against these charges, but combined with the poorly designed EHR software many notes are intelligible, others appear to have not been written by intelligent beings. Quite ironic that these same agencies have now mandated an abstract because they have also mandated all of the other irrelevant points that make the note unreadable in the first place.

    It is long past the time that EHR mandates need to be on the manufacturers and not physicians. All EHRs for example, should demonstrate that med reconciliation at all points can be done effortlessly and at least as fast as a physician writing out the current medications by hand.

    If not – that software should not be certified as being usable in medical settings.

    Time to design the software to reduce the clerical burden on physicians and not increase it. There are currently no incentives to do that.