August 10, 2011

Why I Am Passionate About Healthcare Information Technology

Filed under: EMRs — HankMayers @ 11:19 am

As most of my followers know, I have spent the past few years engaged in motivating physicians in adopting electronic medical records and particiapting in opportunities to electronically integrate their care (and their electronic records) with other practitioners caring for their patients. Like most people in this field, the persisting lower-than-predicted adoption rates can be rather discouraging and financially disappointing. However, as I recently experienced the risks that the world of paper records create for anyone receiving care in today’s paper-based healthcare system. I thought I’d pass it along as an energy booster-shot for those of us pushing the HIT ball up the steep hill of physician adoption.

Because of my professional knowledge of the risks associated with today’s largely paper-based inpatient care system, I take a very active role in monitoring the care and recordkeeping of any loved one who I visit at a hospital (with my aunt, I have MDPOA). My aunt, who suffers from a life-long mental illness, was recently admitted to a hospital with pneumonia. Midway thorugh her stay, my aunt’s provider was going to restore my aunt’s Zyprexa dosage to her ambulatory norm of 10mg/day (from the earlier 5mg per day), I was curious to make sure that it had actually occurred. I found that her paper Medical Administration Record indicated that her order had indeed been increased – to 10mg 4 times/day. I oversee all care provided to my disabled aunt, so I knew this was an extraordinary level of medication. The 1st 10 mg dose had already been administered, and she was due to get the 2nd in 3 hours.

Upon arriving home, I jumped on the web and confirmed that was a dangerous situation. I immediately called the nurse’s station at the hospital and directed that they not administer the next dose until after they personally spoke with my aunt’s psychiatrist who was part of the official care team (I was adamant that the hospitalist would not be sufficient). I then placed an urgent call with the psychiatrist’s service as a precautionary measure. 20 minutes later I received a call from the nurse that my aunt’s MAR and chart were being revised to reflect 10mg per day.

Being a firm believer in the importance of modern HIT, I returned to the hospital the next day to see how this error happened. My conversation with the nurse, who was very helpful, revealed that someone had interpreted a 10mg qd sig (Yes, it was a hand written order, though not particularly indecipherable) as 10mg 4 times a day (qid). One of the particularly surprising side elements of this story, is that the hospital has a modern in-patient pharmacy system that should have fired a dosing alert to the pharmacy staffer that filled/dispensed the order. If it did, there was no chart record of a clinical warning having been waived.

One interesting post-script: While the nurse was most apologetic, I never received an apology from someone in management at the hospital.

Anyone have a similar story they’d like to share?

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