Last week my mother fell and broke her hip.
She was taken to a very good local hospital and received excellent orthopedic care.
The hospital used certified EHR technology and did their best to reconcile her medications.
They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).
Although are her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard). There was no way to seamlessly exchange and synthesize all her data from various sites of care.
Meaningful Use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation. OpenNotes is not yet universally adopted across the country.
When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.
After receiving medication, she was not able to accurately reconcile her own medications.
My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list. The best he could do in addition to his notes was to bring in every medication bottle he could find at home.
By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.
Her mental status on 22 medications was such that she was not oriented to person, place, or situation.
To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status. Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans.
My role as her son and her healthcare advocate was to assemble the care team and explain that she was TWO medications at home, not TWENTY-TWO. How did this happen? In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications. In an effort to be complete, the hospital placed her on all of them in standing doses. Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking. She ceased to be able to participate in physical therapy because of difficulty understanding the training.
Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.
The next morning, my mother asked why she felt so foggy. She had no recollection of the previous two days or any of the visitors who spoke with her. She regained her involvement with the rehabilitation process and became a partner in her care planning.
Under stage 2 of Meaningful Use, patient and family view/access/download/transmit to her various data sources will be required. Data exchange at transitions of care will be required. Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.
As I wrote yesterday, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory. We need to walk before we can run. Clinicians throughout the country are rapidly adopting more advanced EHRs which support the workflow needed to prevent the problems my mother experienced. Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support. These changes are occurring at fast pace but an appropriate pace. The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe Meaningful Use can or should be done faster than the current timelines.
To those who say that the industry should have solved all these issues years ago, I respond that 9 women cannot grow a baby in a month. It takes the focused energy of 1 woman for 9 months.
I look forward to Meaningful Use Stage 2 and 3. My own family experiences illustrates why the path we're on is so appropriate and so essential.
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11 comments:
An excellent example and explanation of the problem, thank you, John. Your patience with the process is admirable, even as you know your own mother would have benefited if Stage 2 were here now.
Any person would be confused, groggy etc with 22 medications give in one day. Can you imagine the distress that a non medical person would have with the same situation.
My personal PCP told me he did not think any person should be on more than five medications and if you give a new one you should take one away.
We have no ideas of the interactions of the combined meds that a lot of people take.
John, you need to run for Congress. When people like Todd "Legitimate Rape" Akin are representing us on the SCIENCE committee, we're in a boatload of trouble. Your hospital service is great, Green Acres is great, but we need brilliant people like you steering our national policies much more urgently than we need either of those.
Thanks for sharing this story. It's important for people to have real-world examples supporting the move to MU 1 and 2, and the government's role.
Great anecdote, John. I'm curious to know if you've seen any great software to reconcile medications across all providers. You've highlighted the need to obtain the most current information, but the process of actually reconciling these is still manual for most of us; we compare what was prescribed at various offices/facilities and manually pick those we think are current. We need to manually transcribe those (rather than importing). It would be great to have software that compared the list in "my" system, to lists in other systems (SureScripts, HIE, PHR, etc), and allowed me to pull in the ones most accurate at this time. My current EHR certainly doesn't do a good job of it.
A final note: this is all going to be difficult until providers and pharmacies are exchanging information about what is stopped. I can't imagine the guess-work for pharmacies when I increase the dose of lisinopril. How can they be sure I am stopping the last dose? Perhaps I'm meaning for both to be taken? The concerns go on. I've heard some talk about this at HIT Policy Cmte (I think), but I'm anxious for a fix.
This story is the unfortunate reality presently. We are thankfully on the path to transformation. Medication reconciliation is a priority. Any nurse will tell you that if we are lucky- the patient or family arrives with meds written on a piece of paper/paper towel or maybe the pill bottles (sometimes ALL of them from many years!). The need for education across stakeholders related to the value of Health Information Exchange is paramount. Those of us involved in the healthcare trenches authentically know the stories- both professionally and personally. Sharing these stories in a compelling way as you have done will inspire action in others.
There is a larger issue here that will not be fixed by data sharing. What is most important is what the patient is actually taking, in what dose, frequency, and who prescribed it and why. The responsibility to make sure the patient has an updated list and they or someone in their confidence, family member, friend, or an involved agency, knows this list. This is more having bright lines of responsibility and offices organized in a way that promotes good practice. The computer is a tool. It is no substitute for thoughtful, efficient patients, their proxies, or their caretakers.
John,
This is not an example of why we need better med reconciliation. It's an example of why "reconciliation" will never work. Every informaticist, including you, understands how impossible it is to maintain data integrity simply by scattering around multiple lists which then need an added workflow process within every silo to reconcile those lists into multiple "master" lists.
We need one list for meds (along with problems and allergies, stewarded by the patient, attached to each EHR/EMR at the front end of an encounter and detached back to patient stewardship at the close of each encounter.
This has not happened for a simple reason: there's no business driver behind it. If such a core profile is not vendor-able, no one will pay for it; if it is vendor-able, then multiple vendors will want to own it as the patient's proxy, and then you do not have a single list anymore.
This is the problem we need to tackle, and it is solvable. We will never get to safe medications until we stop trying to exchange every med list everywhere. We do need to exchange a lot of clinical information, but we need a centralized (dare I say, cloud?)core, including meds.
I can't think of a better proof case than this near-disaster with your Mom, and I speak as a fellow ED physician with feet in the clinical and vendor worlds.
In general, vendors are doing a good job trying to keep up with MU2 and beyond, but until the paradigm for exchange changes, we'll be doing an awful lot of work that will not prevent this exact scenario...
Thank you for sharing your story. I think many of us who have cared for aging parents have experienced similar, troubling situations. These experience makes the work we are doing in RI around our HIE (CurrentCare) even more vital and urgent. We have to solve this problem and we will.
I think it's good that you put this thing in front of everyone. This way everyone learns from each other that recognize good and evil. It reflects our stage systems.
The fiasco that is Medication Reconciliation is the result of the Joint Commission mandating a single “source of truth”, without a detailed plan on how to accomplish this, or even asking anyone in the trenches if such a task is possible.
As a former Director of Pharmacy, I watched the volume of medications dispensed increase by 15% the first year of Medication Reconciliation. With each passing year, and improvements in the electronic health record, I observed medication lists growing larger upon each patient admission. Today, normal medication lists contain 15 to 20, or more, drugs. In some cases, medication lists for complex ICU patients contain 35 to 50 drugs. Pharmacists attempting to intervene on the patient's behalf often throw up their hands and surrender when they are told that they need to talk to the person who wrote an order - somewhere in the electronic past.
Dr. Jim Thompson's comment hits the nail on the head, but barely scratches the surface of the complexity we have all been tasked with.
Yes, we need a national database of every prescription filled, including those paid with cash, but:
1. Who is going to create and maintain this cloud?
2. How will changed or discontinued orders be communicated to this cloud? (remember, the intent to discontinue “Lasix” given twice daily in the hospital, does not translate to the patient's once daily “Lasix” prescription at the pharmacy)
3. How will we identify an individual medication order in this cloud? (Sorry, the NDC number, or National Drug Code, of “Lasix” will not work since the same chemical entity has a different NDC number from every manufacturer and those numbers change over time)
4. Which medication order is the most current? (real time update during hospital stay)
5. Who is the arbiter with authority to correct any corruption in the database?
I could add at least twenty more elements to this list, but my point is that Medication Reconciliation will never work without fundamental and universal changes to the nomenclature and ordering of medications. Like it or not, this will have to involve multi-agency Federal regulatory changes that all software vendors, drug manufacturers, hospitals, physic, and pharmacists will have to comply with.
Current Medication Reconciliation is even more detrimental than the old, handwritten med list that used to be attached to the first page of the chart. As it stands today, every patient needs an ombudsman to represent his interest in receiving safe and effective care.
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