Editor's Note
A Fouled-Up System
As a primary care internist, I don’t cut, I don’t deliver, and I don’t catheterize. Although I do counsel patients on lifestyle and order nonmedical treatments such as physical therapy, many of my patients walk out of my office with a prescription. So you would think after all these years I would be an accomplished pill-pusher. But I’m not. Getting patients to take the right drugs is what I do poorest.
It should be simple, just like a recipe. Write out instructions and patients follow them. Yet study after study shows that the system breaks at every turn. Patients don’t understand instructions, get their pills mixed up, or just don’t take them. Pharmacists can’t read prescriptions and can’t reach providers. Hospitals have to make endless calls to verify medication lists on admitted patients, and, despite tireless efforts to get it right, discharged patients’ medications get fouled up. There are a lot of players in the administration and use of medications, and getting everybody on the same page somehow doesn’t seem to happen.
As the “quarterback” in patient care, we primary care physicians should be able to get it right. But we see patients who have no idea what they’re taking—“It’s whatever it says there in my chart, doc” or “It’s the blue ones.” (Patients know colors, doctors know names.) We see patients who keep a medication list in their billfold, but it is a tattered, faded, folded piece of paper that was last modified four years ago. We get the puzzled inquiry from the pharmacy about the 50 mg atenolol that should be 25 mg. And we search 20 different pharmacy refill request fax forms for the right boxes to check.
If all these glitches were mere inconveniences, perhaps we could live with them. But mistakes can sicken or kill people. So how do we ensure patients are taking the right medications the right way every time? I dream of a perfect world with a master medication list, accessible to patient, doctor, pharmacy, and hospital, that registers changes instantaneously and warns everybody of dangerous drug interactions. The electronic health record (EHR) potentially could supply that list; but the EHR evolution is going the way of American capitalism, and at present, we have a supermarket farrago of systems being adopted by doctors, pharmacies, and hospitals. My clinic is currently installing an EHR on the platform used by the hospital we use. But if my patient has surgery at a hospital that uses a different EHR, that patient’s information will flow back to me by the same inefficient, fallible routes it’s traveled for years. And most pharmacies cannot yet communicate electronically with our EHR, so our fax machines will still be spitting out refill requests.
Perhaps someday there will be an electronic millennium, when all of the players in the medication melee will sit at a table, U.N.-like, and agree to communicate for the sake of patient safety. Yet even if that comes to pass, we won’t have a solution for the human factor. Before he died earlier this year, my father-in-law was on about 10 medications. He was a meticulous retired dentist who prided himself on keeping track of the details of his life. But despite this and despite my wife’s doting attention, he got his medications confused. When pill goes from bottle to mouth, no electronic gadget can help—if it’s the wrong bottle.
I hope that I and the rest of the health care delivery system can get all this right some day. In the meantime, I’ll keep writing prescriptions.
Charles R. Meyer, M.D., can be reached at cmeyer1@fairview.org