Tuesday, May 23, 2006

Medication Errors: Perhaps an Answer Exists

Laura Landro in today's issue from the Wall Street Journal describes an initiative hospitals are taking to collect better medication information on their patient's in a rather feeble attempt to prevent medical errors. This is in response to a national patient safety standard that went into effect in January called "medication reconciliation." This means hospitals must have in place means for collecting complete drug and allergy histories and comparing them with new medications that their doctors order.

Stanford Hospital has initiated a "Vial of Life" program with local EMS services where the patient's medication lists are printed on paper and placed in an old medication vial and stored in that highly accessible and often visited location: the refrigerator. Huh? Have you ever heard the adage, "Out of sight, out of mind?" This seems like an unlikely place to keep medication changes up-to-date and current. People I know don't carry a refrigerator. Perhaps most important, the reliance on patients to become "more proactive" in knowing their medications is sure to fail. When I see patients in clinic, most don't know the names of medications, but might know they're on a "water pill" at best, and more often have NO idea the purpose of each medicationn, let alone their names. On top of this, to expect them to know the milligram dosage of each drug is unrealistic. And that dosage, which has been stored in the refrigerator vial for 6 months, is not likely to be updated. Sincerety and spin don't save lives.

I am fortunate to work in one of the "100 most wired" hospital systems in the country. Yet even our system is insufficient. We use the EPIC medical system, touted to be the next frontier of health care, that is integrated between the outpatient physicians' offices and the hospital. Medications entered by the patient's outpatient physician alters the same medical record that providers within the hospital see. This adds incredible continuity of care on many fronts. But I am frustrated at the incredibly complex screen that is displayed when I reorder a myriad of medications and have to "reconcile" their complex and innumerable interactions. More challenging is that if my patient travels to a physician's office outside our network, no information can flow easily with them. Suffice it to say, this system goes well beyond "the paper in a vial" approach.

It was with awe that I had the chance to meet with Ross Fletcher, MD, Chief of Staff, from the VA Medical Center from Washington DC last week. Ross has been instrumental in developing and promoting the VA's Vista Electronic Medical Record (EMR) used by the VA Medical system, and a model for the EMR industry. Best of all, its free. It's power is demonstrated in its ability to incorporate geographically disparate graphical and data-driven information and display it for the physician in a organized, easy-to-comprehend fashion on any commercially-available computer screen. And this data is culled from every VA medical center across the United States, in seconds. Information from a VA in California, Utah, and Washington can be viewed side-by-side in chronological order.

While sitting with Ross at dinner, his pager went off. He looked down, smiled, and delighted in the fact that a seasonal variation in effectiveness of therapy was suggested by analyzing over 1 billion vital signs on veterans collected over the preceeding five years across the U.S. using multivariate analysis. The sleepy old VA?

And you can bet their medication lists are up to date.



Anonymous said...

I can agree to an extent. Along with placing the vial in your refrigerator you also place a sticker on the outside of the fridge. An EMT I know says that he was trained to look for that sticker on the fridge. I figure meh, it doesn't cost anything to do and there's an off chance that it might come in handy.

When I was a patient at Stanford though, the thing they stressed was keeping a card in my wallet with my prescriptions and dosages and doctor's names and numbers. This is something I continue to do.

The other debate is a Medic Alert bracelet. Medical professionals can call the Medic Alert line and they have all of the information one might need including meds, allergies, and doctor information. That same EMT I spoke of above thinks these are a waste of time.

What are your thoughts? What is the best way to get this kind of information to the care provider in an emergency beyond having the patient memorize the list--particularly if the patient is incapacitated or elderly.

My GP also uses the computer system you've spoken of and it's awesome to now have to list all of my meds each time I go in. But not all of my care providers are at the same facility which makes this difficult.

DrWes said...

Our practice is also to provide information on the MedAlert bracelet program with our patients who have significant medical issues (anticoagulants, complicated antiarrhythmics, installed medical devices, allergies, etc.). It is remarkable that this nation-wide, 800-number system was not commented upon in the WSJ. ALL EMT's that we interface with look for bracelets or necklaces (or the wallet card) with this system, and it STAYS WITH THE PATIENT. Many of our patients aren't at home when emergencies strike: another reason the refrigerator idea seems ineffective.

Regarding the EPIC EMR: While it is nice, it has NO graphical information, except that linked to other systems or scanned and displayed using a PDF file. It is remarkable that the VA system has graphic integration, is written in the same language as EPIC (MUMPS) and has an open architecture. And the reason it's not incorporated into EPIC? Simple. It's all about the money. I guess that's what keeps the development of such systems rolling....