August 9th, 2015

The Pain — and Potential Power — of Electronic Health Records in One Little Anecdote

Doctor at computerHere’s a scintillating series of events that happened recently on our inpatient consult service:

  1. Reason for consult: “Treatment of UTI in a 26-year-old pregnant woman with multiple allergies.”
  2. Culture result:  Group B strep, resistant to clindamycin and nitrofurantoin. She’s been on the latter.
  3. Patient’s allergies as listed on her chart:  Penicillins, cephalosporins, sulfonamides.
  4. Plan per OB service:  IV vancomycin, consult ID service, admit?
  5. 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.
  6. 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.)
  7. 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.)
  8. Patient’s mother is called:  No answer, voicemail is full. (Yes, it’s a national epidemic.)
  9. 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.
  10. 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.
  11. 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.)
  12. 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.
  13. 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.
  14. Chances of this “ticket” being resolved in time to prevent said admission:  About zero.
  15. 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.)
  16. 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.
  17. We start considering “second line” treatment options. Fosfomycin? The OBs don’t like that plan. Group B strep spooks them.
  18. Another obstetrician overhears our discussing this case. She just happens to work at this group practice one session/week.
  19. 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.)
  20. 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.
  21. Patient is reminded of this. She says, “Oh yeah.” She’s discharged home on cephalexin.
  22. 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:

  1. All EHRs should have web-based access.
  2. 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.)

13 Responses to “The Pain — and Potential Power — of Electronic Health Records in One Little Anecdote”

  1. Mary Cairns MD says:

    hear! hear! The implementation of such solutions would be truly “Epic.”

  2. Loretta S says:

    “No information. (This omission should be punishable by a very high fine.)” Hear, hear! I tell the student nurses I teach to ask the follow-up question and document WHAT the reaction was. A lot of times, the patient will say something like, “Oh, I had severe diarrhea”. Sorry, not an allergic reaction, just darned unpleasant. More typically with penicillin, they say (as your patient said), “My Mom said I had a bad reaction as a baby”. On further questioning, the patient does not have a clue what said reaction actually consisted of.

    P.S. That practice’s EHR went back 13 years? That’s pretty amazing in and of itself.

    P.P.S. Recently had to write paper progress notes when our power was lost during a bad storm. I must admit, it was much simpler and almost relaxing. No endless pull-down menus! And seeing patients by flashlight was an interesting experience.

  3. Daniel Gluckstein MD says:


  4. Bryan Siegfried, MD says:

    My EHR has much of the functionality you are talking about for the patients, but even mentioning it with almost every patient during the visit (front desk asks, too), and still we have fewer than half signed up, with far less than 10% even using in a rudimentary way.

  5. Mimi Breed says:

    A writer and an illustrator married to each other…what could be better! Paul, you’re my favorite blogger.

    • Paul Sax says:

      A writer and an illustrator married to each other…what could be better! Paul, you’re my favorite blogger.

      Mimi, that’s my sister Anne! Hope I’m still your favorite blogger.

  6. Cathie M Currie, PhD says:

    Even better: a patient EHR hub, where links to all medical encounters could/would be stored.

    And, unknown to most people, medical record hubs exist but not to benefit to pts or their physicians. Index Bureaus, e.g. Medical Index Bureau, serve the insurance industry and lawyers. Never mind that they aren’t caring for the patients and violate privacy rules.

    A patient EHR hub would require a national health service in place. Oh that. And trust. Oh THAT.

    In my postdoc, I looked for cramped margin notes to help us see our child psychiatry pts’ broader medical picture. Can’t imagine how some pts would fare today with only psychiatric sx in their psychiatric chart.

  7. Robert Deutsch says:

    you could have give her one dose of IM ceftriaxone and
    called her doctor in the AM.

  8. karen says:

    Karen Kramer You need to remember that this was built as a billing system. The communication pieces are secondary and added to try to give a positive spin to providers and patients. BUT – it is a billing system built to be sure no one ever misses a charge. My opinion is that the loss of bedside nursing care at the hospitals has been a result of not being able to bill for that time. If you are hanging a bag of IV antibiotics or measuring and documenting – that can be documented, but a bed bath, back rub, escorted trip to the bathroom, help with brushing teeth, extra blanket…..those things can’t be charged for – are relegated to minimally trained staff. I had the privilege of being a nurse when we actually could care for people and help them get well before we sent them home. Most studies show that no matter what interventions are offered – including preventing pre-term labor…., the relationship with the provider/nurse is what brings healing or behavior change. You can’t bill for that. Don’t get me started….

  9. jsax says:

    We use MyDH (figure out where that is). Recently I had seen an out of state physician and when I returned home, I tried to upload the report so that my primary physician could refer me to PT. However, even though I followed all the rules of the type of file (.pdf in this case because I scanned the file) and the size of the file, the system didn’t work. I ended up speaking with the IT people and they couldn’t diagnose the problem. In the end, I faxed the file (old technology, but that was the only alternative other than US Mail) so now it is sitting on a desk waiting to be uploaded onto my electronic file (not going to happen any time within the next year). The physical therapist did not have the report with the diagnosis. My point is that even when there are electronic files that the patient and the physician can access, often they have not been sufficiently tested to ascertain that they in fact work. I am betting I am the only patient that even tried that non-functining feature.

  10. The lack of interoperable electronic medical records is a frequent barrier to patient care.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.