Medication Small Print

WhenSolu-Medrol_crop I give a cortisone injection, I have to document it in our electronic medical records. I’ve always included the dose, how administered (intramuscular), and the lot number. This week my company added the requirement that we include the NDC number, as insurance companies wanted the information.

It’s just one more administrative requirement, but what really makes it bad is trying to read the number off the bottle. As you can see from the photo, the font is very small! I suggested the policy was age discrimination, but that didn’t get far.

Dangers of a Transparent Medical Record

Over the years there has been a push to allow more patient access to their records. Patients in our system that have signed up for MyChart with our electronic medical record Epic, can see most of their test results shortly after they are back, even if not yet reviewed by the physician who ordered them.

To avoid patients misinterpreting or reacting badly to the results, certain tests, such as HIV and pathology, are not automatically released. Although releasing the results automatically acts as a safeguard for abnormal results that may have been missed by the physician, it also opens the possibility of patients inappropriately acting on the results.

I’ve had patients make changes in their medications after seeing their results, and without even discussing it with me until their next visit. One patient who saw that his sleep study showed he had sleep apnea, borrowed a friends extra CPAP machine, adjusted the settings based on his research on the internet, then tried it out for 2 weeks!

As the saying goes, a little knowledge can be dangerous. Patients should use the information in their charts to inform them, and help ask educated questions, but not to replace their physician. There is often a lot more to making a diagnosis and deciding on a treatment than just looking at test results.

Spam Flattery

You’re familiar with email spam, but what you may not know is that people also try and spam blogs by posting comments that in effect are actually advertisements. Some of these spammers are cleaver and don’t come right out making a pitch for their product. What they hope for is that you will read their comment then be curious to click on a link to another website associated with their name. Spelling and grammatical mistakes may be accidental, or intentional to make them appear more like an every day person, but most misspelled words are probably attempts to confuse computer spam filters. Viagra can be spelled wrong so many ways it’s difficult to catch them all.

To prevent spam, many blogs are moderated and must be approved before posting. Spammers must believe in the adage that you catch more flies with honey than vinegar, and often post flattering remarks. Those doing the reviewing are human, and may be more likely to accept a comment praising their site. If you use Google or other search engine and look for the comments below, you will see that most, if not all, of them have appeared on other sites.

Most of the spam on this site is identified by WordPress, however I manually review them before deleting. Here are some of the spam comments I’ve received since starting this blog:

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ifttt Medical Applications

I’ve started using the new web service ifttt. It stands for If This Then That. It allows one to use the internet to create various tasks in a If This Than That structure. The This part is what they call a Trigger. It’s the event that has to happen to trigger the task. Triggers can be such things as every time you add a video to your YouTube favorites or every time a photo is tagged with your name in Facebook.

If a task is triggered, then an Action is done. For example every time you add that YouTube favorite, an email is sent to your friend saying you found another YouTube gem, or you get a text message to your phone when you get a photo tagged in Facebook.

These Triggers and Actions come from what they call Channels. This includes such things as Facebook, Twitter, email, and phone calls. They currently have 41 Channels, and growing. This gives enormous possibilities.

Finally one can share created Tasks, in what they call Recipes, that others can download.

I created some recipes with medical tasks in mind. I wrote reminders to take one’s medications. This can be done with a text message or phone call. You could use it for yourself, or set up an account for a friend or family member that needs help remembering to take their pills. You can find the recipes at: http://ifttt.com/people/ginsberg.

Epic Customizations

Epic is the electronic medical record (EMR) I use at work (actually my company calls it MultiCare Connect). There are a number of customizations one can do to increase efficiency, and I’ve done a lot. Keep reading to learn just how much.

There are SmartPhrases. These are shortcuts to write out text. Instead of writing “past medical history” one can write “.pmh” and it will automatically enter the three words. A SmartPhrase can contain other SmartPhrases enabling one to generate the shell of a note with a few key strokes, then just fill in the portions that cannot be automatically added.

There are SmartLists. This allows one to basically use a drop down box to select one or more options. Although I have 55 of them, each one consists of multiple entries. For example, if I want to enter the specialists a patient sees, I may select the cardiology and gastroenterology SmartLists, then select the physician the patient sees from each list.

There are a number of different Preference Lists. This is typically used to order various things and save them in the way you want, to save time later. In my Medication Preference List, for example, for an antibiotic it may say to take the medication twice a day until finished and include the proper amount of pills. In the description I write that it’s an antibiotic so my patients know what the medicine is for, and to lessen the chances the pharmacist may misread it. I also include an end date so the medication won’t show up on the patient’s medication list after they have finished taking them. It’s a bit of work, but once saved, it’s very quick to use in the future.

SmartText is kind of a SmartPhrase tied to certain situations. I’ve probably written more than one, but there is no easy way for me to look up which ones I’ve created.

SmartSets allows one to set up templates to do such things as place multiple orders and associate them with diagnoses and notes, and basically speed up various paperwork we have to do. Unfortunately a few years ago Epic made it much more difficult to write or edit SmartSets, so I’ve pretty much stopped working on them.

Letter Templates are just like they sound. I have one to tell women their PAP smear was normal, one to ask their employer to excuse them from work, one asking for a patient to be excused from jury duty due to their medical condition, etc. Unfortunately, as with the SmartSets, it’s no longer easy to write new ones or modify my existing ones.

For the medication dictionary, not only can I add words, but I can set it to auto correct words. If I type “referal”, for example, it will automatically change it to “referral”.

I use Dragon NaturallySpeaking to dictate parts of my notes, but I go beyond with custom scripts. For example, if I say, “order anemia panel” it will enter the proper codes for a CBC, iron/TIBC, ferritin and vitamin B12.

I’m constantly updating, but as of last week, these are the customizations I’ve done in each category.

Tool Number
SmartPhrase 1203
SmartText 1
SmartSet 28
Letter Template 16
Dictionary 5861
Preference Lists
Charges 4
EKG 3
Office Visits 1
Education 3
Immunizations/Injections 13
Labs 335
Imaging 170
Medications 3594
Orders 3
Procedures 41
Referrals 278
Supplies 2
Dragon Scripts 302
Total 11914

Each of the 11,914 items is a customization. It may be as simple as a word added to the dictionary, or represents paragraphs of text, a list of hundreds of items, or dozens of lines of computer code. Having been on Epic since 1998, that means I’ve averaged about a 1000 customizations a year.

All these customizations makes Epic very powerful, but unfortunately it was not designed well to share. Many of the items, such as Preference Lists, can be shared, but only by individuals importing someone’s list. If someone imports my Medication Preference List, it goes out of date as soon as I make a change. My list is so long it may take 5 minutes or so to import the list, and even if faster, most people are not going to remember to import the list regularly. It’s like backing up one’s computer. If not set to do so automatically, most people won’t do it. In addition when one imports someone’s list, it doesn’t show where it came from. I think it would be far better if people could subscribe to preference lists similarly to how one follows people on Facebook or Twitter. My medication preference list was designed for internists seeing adult patients. A family practitioner should be able to subscribe my list, to use on their adult patients, and another list to cover their pediatric patients. It is difficult to share customizations within my own company, and far harder still to share with people in other medical groups. Consequently thousands of people have to reinvent the Epic wheel.

Medication Errors

Not infrequently Express Scripts, Medco, or other similar companies send a fax to alert me that my patient is taking two similar medications. Occasionally it’s intentional, but most of the time it means something went wrong.

Sometimes I change a patients’ medication to something similar to achieve better efficacy, to minimize side effects, or due to cost. Although I always put the changes in writing for the patient, telling them what to start and what to stop, this doesn’t always work. Patients may get an automatic refill of the original medication from the pharmacy or call it in when they notice a pill bottle is almost empty. Sometimes they go by a medication list they’ve generated, but not updated, rather than the printout I give them.

Sometimes patients end up on two similar medications after getting one from a specialist who doesn’t realize a patient is taking something, because the patient didn’t bring the list I gave them, and they don’t remember everything they take. For example I might have the patient on lisinopril for hypertension, and their cardiologist prescribes the similar benazepril.

A similar medication error happens when we tell patients to stop a medication and they don’t for similar reasons as above.

So the faxes are helpful when these things are caught, but it would be better if it occurred at the the time the prescription is sent to the pharmacy.  Ideally the pharmacy computer would automatically connect to the physician’s electronic medical record (EMR), particularly the primary care doctor, and compare medication lists. If they had medications to refill that didn’t match the EMR record, they would call to double check if the patient could not give them a good reason for the discrepancy. In addition, the pharmacy computer could keep track of all the chronic medications a patient has filled. If the patient doesn’t get the prescription refilled in a timely manner, their computer would query the physician computer to make sure it was still an active medication. If so they would call the patient (and maybe in the future talk to the patient’s medication list carried on their computer/mobile device) and remind them to refill their medication, assuming someone hadn’t stopped it, the patient was taking samples, or some other good reason.

If you use a program such as Quicken, you can download credit card and other transactions and reconcile them with entries you’ve entered. Comparing medications would be a similar process.

There are certainly barriers to such a solution. Electronic health records would need to have medication fields standardized, and there would need to be protocols to exchange the information. I’m not sure, but I think some of this already exists. Of course there are legal issues such as HIPAA.

As John Lennon said, “You may say I’m a dreamer, but I’m not the only one. I hope someday you’ll join us, and the world will be as one.”

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