What good does an EHR do even when a thorough preliminary screening and review w/ documentation of medical history of the patient do IF THE CLINICIAN FAILS TO LOOK AT THE INPUTS.

I only mention EHR because the typeface is theoretically the most legible format (font) that one could possibly have in front of them to peruse upon meeting the patient in the exam room.

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So, here's an interesting scenario - that could have gone very bad (and caused patient to drive off the road).  The DDI's were double vision, slowed reflexes, and impaired or slowed thought processes.

Patient gets prescribed 3 new medications for Problem X, a diagnosis which is arrived after a 45 minute visit (quite thorough, I'd say, for any specialty).  Patient picks up meds following visit, and begins taking them as prescribed. 

Within a few days, a punch-drunk stupor sets in followed by double vision and extreme mental fogginess w/ lack of clarity of thought; no loss of cognition and slowing of reflexes, but no loss of good judgment in decision-making; temperament intact, in fact, too mellowed out.  The biggest issue:  Patient simply cannot focus on objects or TV screen, despite having far-sighted vision.  Double vision and watery eyes.  (Anti-cholinergic affect, possibly a touch of seratonin syndrome.)

Patient calls clinic, as one should do.  But many of our patients do not; they just keep going with side effects they think they have to tolerate.  Or, alternatively, many patients just give up on the medication not realizing that a simple dose adjustment or other med could be considered.  So, we have no chance to advise them over the phone.  Then, instead of seeing them back within a few days or a week, they merely show up for their routine appoint 1-2-3 months later.  Herrumph.

As for patient in this scenario, clinician returns call and med list is reviewed - one that had originally been provided thoroughly (bag of meds was carried into initial visit).  Clinician states that he did not realize patient was on this one particular med causing DDI and also this other med that may also be adding to this untoward adverse reaction. 

Result: patient has one med withdrawn, one continued, and the third is halved (via use of pill-cutter).

Yeah, this actually happened to someone I know.  Glad they are safer for now, and are following up at this otherwise very good clinic very soon.

But question remains:  if I am required to get it right when I prescribe (held to high standard), how did this type of clinic w/ EMR and a nurse doing a thorough pre-screening get it so wrong?

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For my part, when in doubt, in the patient with poly-pharmacia, I ask the PCP if it alright to prescribe something as NOT benign as Neurontin or a Pain medication -even Tramadol. 

As I've said before, for cardiac patients, especially if they are on Coumadin, etc., they are NOT candidates for ANY type of pain med nor NSAID.  Local treatment, procedurally speaking, usually palliative (e.g., injection, lidoderm/gel/oint) and padding, strapping, & orthoses is the MOST & BEST (& RIGHT) & ONLY treatments that we can do.

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Now, a complaint I have heard from Podiatrists, as well as other sub-specialists, is that many patients continually fail to bring in their list or bag of meds, cannot remember all of their meds, or simply willfully do not disclose ALL of their prescription medications.  IN addition, many patients are not only poor historians, but they also by choice do not tell us, their foot doctors, everything.  WHy?  Who knows.  Not that important, what could it matter, not going to affect what we do, or we're just a toe doc- I can try to emphasize the importance of revealing everything in order to best help them and avoid hurting them with the wrong treatment or prescription... but, some patients are stubborn and think they know better. 

Besides, let's face it, many patients, even parents, are squeaking a script for Tyl#3 out of us- say, following a procedure, not for the patient per se, but for someone else, the parent/spouse, or for it's street value.  I saw it all the time in the under paid private in the army who had too many kids; but that mostly before they slapped the foodstamp allotment onto their pay check.  However, many still went down town and sold them at the tavern on Fri nights... info which came back to me thru my more honest patients who also frequented such extablishments (there wasn't much to do for young people where I was stationed in west central Louisiana).

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We can preach thorough H&P taking all we want, and of course never give up on doing so; but the fact remains the human element is often a tricky hurdle.

Moreover, it is too easy now to use EPOCRATES in order to verify DDI's on one's smart phone.  But that requires looking at the list of meds, hoping that it is thorough, and taking 2 minutes to actually do it.  That is what I'm touting here.

Download free version at www.epocrates.com.  It even gives you the current formularies by insurance company, which takes only seconds to check.  Unless you simply don't care, which I've had docs tell me when they prescribe.  To me, that means or tells me that physician-surgeon-podiatrist does not care whether the patient can afford it, whether their insurance covers it, nor even if they pick it up and take it.  The upshod being, why waste time diagnosing and attempting to treat the patient like you care?  Was it just a charade?  Sounds like it's getting time for you to have an attitude adjustment or maybe its closer to retirement than you think, my good fellow.  Yeah, I've seen that, and yep- I said it outloud.

Have a nice caring for your patients day.  Or not- the caring part, I mean.

WG

P.S>  Bring the heat, anyone?!

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