EMRs as a tool for patient safety.

A short jaunt over to the EMR and HIPPA weblog led me to an interesting article in Time written by Scott Haig, MD. While Dr. Haig touches on a couple of positive features of electronic medical records (EMRs), he like many physicians, focuses on the negatives. He concludes that “Doctors and patients live in a world of painful, pressing questions. The great physicians I’ve known seek answers through personal commitment to each patient and judgment born of practical experience — neither of which I have found in a machine.” I think he is missing the point of an EMR.

While there are several definitions of an EMR, the basic components consist of clinical documentation (physician notes, history and physical, care giver notes, discharge summary), laboratory data, patient demographics, prior encounters, pharmacy, radiology results, etc. More advanced ideas of an EMR may include computerized provider order entry (CPOE) and bedside-barcode-scanning. Like all technology, an EMR is designed as a tool to help not only physicians, but all healthcare workers involved in the care of a hospitalized patient.

While it is true that a computer cannot take the place of a physician’s mind, it can certainly help correct a poor decision making process. Examples where an EMR may be useful include illegible physician writing or the continuous battle of prescribing medications for patients with allergies to a like or similar medication. The popular cephalosporin cross reactivity with penicillins is one example.  As a pharmacist, I know the chances of a dangerous cross reaction are unlikely, especially if the penicillin allergy is mild. Unfortunately I am forced to call on every single occurrence for clarification, regardless of my opinion. A notation on the order from the physician acknowledging the allergy and their desire to continue with therapy would prevent my phone call and save valuable time.  Asking a physician to note this by hand on a paper order form is a lost cause. Believe me, I’ve been asking for 12 years with little to no affect. A CPOE system could be programmed to prompt the physician to note the allergy on the order prior to submitting it. Voilà, no phone call from the pharmacy.

How about the order I received a few years ago for gentamicin and tobramycin to both be given to a patient simultaneously. The physician requested dosing “per pharmacy for therapeutic levels of both.” Huh? Only if you want possible renal failure or permanent deafness. The physician indicated that the infection was sensitive to both agents and wanted to “double cover”. After a lengthy discussion I convinced him to use one aminoglycoside combined with a different agent.

Another common scenario is the inclusion of several different pain medications existing together on a patient’s active medication profile. A surgery patient will frequently have orders from the anesthesiologist, the surgeon and the attending physician. With all those hands in the cookie jar the patients profile frequently looks like you were trying to include something from every drug class. Don’t laugh, this is serious business. I can’t imagine the nurse trying to make heads or tails out of orders like these. The solution lies in a system that gently nudges the provider to acknowledge the patient’s current medication regimen and allows for changes on the fly.

A few years back, I was involved in a case where the wrong dose of tacrolimus was accidentally recorded in the patient’s discharge summary. The result was a ten fold overdose to the patient that led to drug induced pancreatitis and renal failure. The mistake resulted in a six month hospital stay including a four week stint in the Intensive Care Unit where we didn’t think the patient was going to make it. This could have been prevented with an electronic medication reconciliation system.

Yet another example where technology could have intervened, occurred when a patient reported dizziness and fainting following discharge from the hospital. An inspection of her medication list reveled that she had been given a discharge prescription for methyldopa, a medication that she had never taken before. No one could explain how the methyldopa ended up on her discharge medication list, but it was filled and taken nonetheless. Fortunately, the medication was discontinued and the patient resumed her normal daily activities without permanent harm.

The list of examples could go on and on, but you get the point. Consider that this is only the point of view from a pharmacist. Now imagine the problem growing as you add several other services involved during a hospital stay (lab, nursing, respiratory therapy, admitting, etc).

An EMR is not only about making information available to the caregiver, but also about helping prevent errors. I encourage people to think of an EMR as a tool to be used for increased efficiency in your practice. I for one look forward to the integration of systems that will provide me with a complete EMR. Anything that makes my job easier and allows me to focus on more important issues surrounding patient care will be a welcome addition.

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