Here's a scintillating series of events that happened recently on our inpatient consult service:
- Reason for consult: "Treatment of UTI in a 26-year-old pregnant woman with multiple allergies."
- Culture result: Group B strep, resistant to clindamycin and nitrofurantoin. She's been on the latter.
- Patient's allergies as listed on her chart: Penicillins, cephalosporins, sulfonamides.
- Plan per OB service: IV vancomycin, consult ID service, admit?
- Why they think this: "Treatment consists of antibiotic therapy with amoxicillin, penicillin, or cephalexin
For patients who have a severe IgE-mediated hypersensitivity to penicillins and cephalosporins, clindamycin is the only oral alternative, if the isolate is susceptible." Said so here, so it must be true.
- Reactions to these antibiotics she's reportedly allergic to, per the patient chart: No information. (This omission should be punishable by a very high fine.)
- Adverse outcomes associated with these antibiotics according to the patient: She doesn't know -- she thinks they all happened when she was a baby. Ask my mother, she says. (By the way, she's not very happy about the prospect of being admitted, understandably.)
- Patient's mother is called: No answer, voicemail is full. (Yes, it's a national epidemic.)
- Patient texts mother, who eventually responds: She says her daughter got very sick when she got penicillin as a baby. She remembers nothing about the other allergies.
- Did she ever have an ear infection or strep throat as a kid or teen? we ask. If she got treated with a penicillin or cephalosporin, and didn't have a reaction, she'd be all set -- oral antibiotics, no need for admission.
- Mother recalls strep throat maybe a couple of times as a teen. Can't remember the antibiotics she received. (You can be sure she's prompted -- Keflex? Augmentin? Z-pak? Nada. Not sure how reliable that information would have been anyway, but worth a try.)
- We find out she received her pediatric care at a local multi-specialty group practice. They use the same electronic health record we do. They are supposed to communicate with each other.
- The promised communication -- "interoperability" is the buzz phrase -- doesn't seem to be working on this particular patient at this particular time. We could "open a ticket" to get this fixed. Then we could access her pediatrician's records, review what antibiotics she's safely received in the past, and avoid an unnecessary admission.
- Chances of this "ticket" being resolved in time to prevent said admission: About zero.
- A call is made directly to that practice. It's after 5pm now. Long voicemail, which includes the ubiquitous, "If this call is about a medical emergency, please hang up and dial 911." (You think? Thank you so much for that helpful advice. And could you go over again how to fasten my seatbelt before a flight? I can't remember what to do with the buckle part and these two strips of cloth attached to them.)
- At the end of the voicemail recording, an option to page the pediatrician on call "in case of emergency". Briefly consider doing so, then come to my senses.
- We start considering "second line" treatment options. Fosfomycin? The OBs don't like that plan. Group B strep spooks them.
- Another obstetrician overhears our discussing this case. She just happens to work at this group practice one session/week.
- She logs into the practice's EHR, looks up our patient's record. (This breaks all kinds of rules. Sorry about that. Actually, not sorry at all.)
- And there it is, like a pot of gold at the end of the rainbow, glistening in the beautiful sunlight: Strep throat at age 13, treated with cephalexin. No allergic reaction.
- Patient is reminded of this. She says, "Oh yeah." She's discharged home on cephalexin.
- There is much rejoicing.
So there you have it -- in 22 excruciating steps, the electronic health record drives you crazy, and then it saves the day. After all, in the days of paper records, it would have been all but impossible to get this information after hours from a local practice not affiliated with our hospital. You'd have to break in, Watergate-style.
Yet it nearly was impossible in this case despite the presence of electronic records throughout this patient's life -- even though the EHR was the same widely-used brand in both places.
The person who cracked the case didn't do so because she was a brilliant diagnostician, or a compassionate clinician, or an insightful researcher (though she may be all of those things). It was simply because she had electronic access to the record, though "officially" she wasn't caring for this patient and in fact violated privacy rules.
So here's a solution to this problem, one that should be implemented right now. Ok, if not today (which is a Sunday), then tomorrow. It goes like this:
- All EHRs should have web-based access.
- All should allow patients to sign in remotely, granting their clinicians the right to see their records to enhance their care.
Simple. Let's get it done now.
(Thanks to the graphically gifted Anne Sax for the pic.)
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.