dialogues in healthcare - the rozovsky group · o dialogues in healthcare © 2016 all rights...

Dialogues in Healthcare © 2016 All Rights Reserved

DialoguesInHealthcareDialoguesInHealthcare STRATEGIES FOR EFFECTIVE COMMUNICATION

Volume 10 Number 1 January 2016

The Disconnect: Failure to Act on Documented Known Allergies Many are familiar with the old saying, “You can take the horse to the water, but you cannot make him drink.” In the healthcare context, one can provide timely, accurate, pertinent information in the medical record, but it is for naught if a care provider does not read important information before formulating a care plan or ordering medical treatment. In the “old” days of hard copy records, provision was made in the chart for noting “known allergies.” Typically, the information was placed in a prominent location to alert caregivers of allergy information. Today, with electronic medical records “known allergy” should be readily apparent when caregivers open a patient record. At the very least, “known allergies” would be consistently added to a section dealing with important patient history and medication information. Even with the most user-friendly designs, electronic records require care providers to “check” for allergy and other information. However, as seen in the case example, there is a definite disconnect between what should be done and what takes place in a busy clinic setting. The lessons learned from the case example highlight the need for a careful review of patient throughput and utilization of documented health information. The Case Study. Nina Longoria was a new patient in the clinic. A 55 year-old administrator in a public school system, Ms. Longoria had a congenital anomaly with both feet that had reached the stage

A Publication of The Rozovsky Group, Inc./RMS

Fay A. Rozovsky, JD, MPH Editor

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that she needed an array of podiatric treatments. Prior to her first visit, Ms. Longoria went online and downloaded a series of documents entitled, “New Patient Forms.” The documents included a Notice of Privacy Practices, an authorization to seek reimbursement from a patient’s health plan, a form that captured medical history and another that focused on current medication that the patient used on a regular basis. In the medication form, provision was made for the patient to list (a) known medication allergies; (b) sensitivities; (c) gluten intolerance; and (d) lactose intolerance. “Nina L., please come with me,” said the medical assistant. She continued, “My name is Toni. I work with Dr. Border. We are going into Room 3. I will take your blood pressure, and get you set up for your examination with Dr. Border. Please remove both shoes and socks and sit back on the examination table.” After recording the patient’s vital signs in the electronic record, Toni said, “I really appreciate your completing all the paperwork online. It makes it so much easier than entering the information into the computer ten minutes before you see Dr. Border. He will be with you in a few minutes.” Dr. Border came into the examination room and introduced himself to Ms. Longoria. “So what brings you to my practice today? Are you having any particular problems?” asked Dr. Border. Ms. Longoria replied, “Well yes. I provided all that information on the computerized forms. I have a progressive, congenital problem in both feet. It has gotten to the point now that I am having a lot of pain in both my left great toe and in the fourth toe on my right foot. I am hoping that you can recommend some treatment that will not include surgery.” “I am looking at the information you completed online. I see you had x-rays about 9 months ago but that you have never had an MRI. I would like to get some new x-rays today while you are here and then compare the results with the set done 9 months ago. Based on that information I may recommend an MRI. For now, Toni will get you a release to send to the care provider who took the last set of x-rays,” said Dr. Border. Ms. Longoria said, “Will you be able to recommend treatment for me today? “Dr. Border responded, “Certainly. Let me look at your shoes, please. Okay, I see you are not using any orthotics. Have you ever tried orthotics?” “Many years ago, but not recently,” said Ms. Longoria. “Please stand up for me, Ms. Longoria,” said Dr. Border. He continued, “Okay. One immediate solution is to take the pressure off the toes that are causing



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you pain. Right now, without any orthotics, those toes are taking a lot of the pressure. I would recommend prescription orthotics. These orthotics are not inexpensive and most health plans do not cover the cost. Alternatively, we can provide you with a generic pair and add some padding to the key areas for pain relief. This way you can try this solution for a week or two and see if it helps. If the orthotics give you sufficient relief, we could discuss getting a prescription pair made for you.” “I would be agreeable with that approach,” said Ms. Longoria. Dr. Border replied, “Good. I will get Toni to bring in a generic pair in your size and our orthotic specialist, George, will come in and apply the additional padding. Now, one other solution that I would like to discuss with you is applying an ointment to these calloused areas. If I am not mistaken, these areas are the sensitive pressure points. Am I correct?” “Absolutely,” said Ms. Longoria. “We can do some treatment to remove part of the built up callous as well. This ‘shaving’ approach can be done as needed. However, if you can keep these areas from forming hardened callous skin, it may really help lessen the pain, along with the pressure relief provided by the orthotics,” said Dr. Border. “This sounds like a great plan,” said Ms. Longoria. She continued, “Please go ahead with what you need to do.” “Very well then,” said Dr. Border. He continued, “After I shave the areas down, I want you to apply an ointment twice a day to the calloused areas. Let the ointment dry before putting on your socks. Do not use it more than twice each day. The office will schedule a follow-up visit in about two weeks for a check up on the orthotics and the calloused areas. If further callous shaving is required, we can do it at that time. Toni will give you a sample starter tube of the ointment. I will send an e-prescription for a regular tube to the pharmacy of your choice. Now, do you have any questions for me?” Ms. Longoria said, “No I think what you have suggested is very reasonable.” As Dr. Border left the examination room he said, “Toni will come in shortly with the orthotics and ointment sample. George will be in thereafter to add padding to the orthotics. Thank you for coming in today. I look forward to working with you.” The rest of the visit went very well. The padded orthotics provided very prompt relief from the discomfort that Ms. Longoria had been experiencing with both feet.



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The next morning, Ms. Longoria showered and prepared for work. She dried both feet and prepared to apply the ointment to both feet. She looked at the packet instructions and some language in small print caused her to stop. Beneath the name of the active ingredient she saw a list of other elements in the ointment. The ointment included oil extracts from tree nuts and sesame, ingredients on her known allergy list. Ms. Longoria called Dr. Border’s office. She spoke with the receptionist who said, “Let me get Toni for you.” Ms. Longoria told her what she discovered in reading the packet instructions. “Toni, I cannot emphasize enough that I am severely allergic to tree nuts and sesame. My allergist told me that if I had a small skin tear that that was exposed to these ingredients it could set off a life-threatening reaction. I think you better talk with Dr. Border about it. You can remind him that I did list these allergies on my electronic patient information forms.” Observations on the Case Example. In patient safety terms, Ms. Longoria completed a “good catch” that helped avoid a serious risk exposure. It was ironic, however, that the person making the “good catch” was the patient, not a member of the caregiving team. How can it be that such a problem could occur in a practice with an EHR system that captured patient information using an electronic platform? During his encounter with the patient the podiatrist had indicated he reviewed her information. Was there a disconnect? Did the podiatrist recognize that some medications and ointments may contain ingredients that could trigger an adverse reaction? Or, did the podiatrist assume that patients listing tree nut and sesame were referring to food allergies? Even if the podiatrist was aware of the fact that some medications might contain tree nut oil or sesame essence, was he familiar with the content of the preparation he prescribed for the patient? Ms. Longoria was quite fortunate in that she took the initiative and checked the labels on the sample medication. She also took the right step to alert the podiatrist’s office about the allergy risk associated with the medication. By taking such action the patient highlighted the importance of care providers confirming the safety of prescription medication for a patient.



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Strategies for Acting on Documented Allergy Information. With the growing sophistication of office-based electronic health record systems, patient information is captured from a variety of sources. Data completed in an online interface by a patient is illustrative of this process. Some of this information may be very relevant to a patient’s care. However, if the data is not reviewed or understood, the information cannot be used to the benefit of the patient. Several strategies may be helpful to act on such patient-generated information, including the following:

1. Education is a Must for Care Providers. Do not assume that all care providers are conversant with using the data input functionality from the patient online interface, or that the data entered by the patient populates expected “fields” in the EMR. Provide user-friendly orientation to the interface along with a readily accessible FAQ on the subject.

2. Equip Care Providers with a “Menu” of Patient Interface Information.

Consider including in the EHR system a “Patient Interface Menu” that delineates what information can be supplied by the patient and also “checkmarks” for those elements completed by the patient.

3. Work with IT and HIM on “flagging” patient risk information. Recognize the importance of highlighting “at risk” information for a patient, such as allergies, sensitivities and intolerances. Discuss with IT and HIM how such “at risk” information can be flagged or highlighted for care providers.

4. Encourage Care Providers to Pose Open-ended Questions to Patients About Possible Risk Factors. Use orientation and in-service training to help care providers ask effective, open-ended questions to identify risk information about allergies, sensitivities, intolerances and adverse reactions to medication. [See Sample Tool]

5. Read Product Ingredient Information Prior to Using or Prescribing It. Stress the importance of reviewing both active and inactive ingredients in ointments, lotions, tablets, capsules or medications in liquid suspension. Compare the information against the “at risk” list information for the patient. Encourage care providers to seek advice from pharmacists or to access online product information for this purpose.

6. Encourage Patients to Pose Questions and to Speak Up.

Recognize that patients can play a pivotal role by asking important questions and reading the content description of medications. Reinforce



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that patients are key partners on the care-giving team and that their input is essential for safe treatment.

Conclusion. Nina Longoria was very fortunate that she “caught” a potentially high-risk situation. She was a particularly astute patient. However, this is not true of all patients. Indeed, most patients look to their care providers to use or prescribe preparations that are “safe” for them in terms of allergies, sensitivities, intolerances or potential adverse drug information. No doubt, it is helpful for patients to take an active role in safeguarding their health and wellbeing. However, even the most engaged patients are not a substitute for care providers acting in an accountable manner to prevent potential allergic reactions to medication. It is imperative that care providers make effective use of patient allergy, sensitivity and intolerance information when crafting a care plan. No one should be dismissive of patient concerns regarding allergies that are usually associated with foods. To the extent that some “food substances” may be used as ingredients in medication, it is important to determine the safety of such preparations for “at risk” patients. With the use of EHR systems, such safety determination efforts require routinely checking patient-generated medication history entered through online sources. It also means conducting medication reconciliation with other data in the HER to prevent serious allergy exposure.

DDIALOGUES IN IALOGUES IN HHEALTHCAREEALTHCARE is a publication of The Rozovsky Group, Inc./RMS. This publication is not intended to be

and should not be used as a substitute for specific legal advice. For additional information on this and other risk management topics please contact us. Contact Information: The Rozovsky Group, Inc./RMS, 3231 Reades Way, Williamsburg, VA 23185 Tel: (860) 242-1302.



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Sample Tool

Training Program for Open-Ended Medication Questions This sample training document can be used to reinforce good practices among care providers when discussing medication allergies, sensitivities, and intolerances with patients. The focus is on posing open-ended questions to encourage patients to provide accurate information. Item Question Rationale Accuracy of patient-generated allergy, sensitivity, intolerance list

“Thank you for sharing this information. I just want to be certain that we have an accurate, up-to-date list of your allergies, sensitivities and intolerance information.”

Patient record may reflect other allergies, sensitivities and intolerances that were not provided via the patient-generated online website intake form.

What have specialists and other care providers prescribed

“Have you seen any specialists? Dentists? Optometrists? Did any of them prescribe medication or encourage you to use over-the-counter medications? Supplements?”

Try to identify other sources of prescription medication, OTC preparations or supplements that could be source of allergy or sensitivity.

Instructions provided by allergy specialists to patient

“Did your allergist (GI specialist) provide you with specific instructions or warnings regarding certain medications or ointments to avoid?” If so, could you share that with me?”

The allergist may have provided the patient with useful avoidance information. Same question could be posed regarding GI specialists treating patients for gluten sensitivities.

Possible drug-drug interactions

“Have you discussed with your pharmacist recommendations to avoid medications on your allergy and avoidance list?” If so, did the pharmacist share information with you that you could provide to me?”

Pharmacist may have counseled against using certain OTIC or generic drugs that have components that could cause problems for the patient such as wheat, soy, lactose, nut or sesame oil.

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