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Pharmanet now, please

At the end of last year, a friend of mine had a small heart attack, followed by coronary artery bypass surgery. He’s had serious breathing problems for years, so he went into surgery with chest congestion and asthma. They kept him in hospital for almost four weeks prior to his operation, trying to get his breathing stabilized..  Happily, things went well, and his heart is good for another 50,000 miles.  His lungs have settled down, and while he’s taking a long time to recover, if he gets enough exercise, he should be okay.

During the post-op period and through his recovery, he’s taking a long list of drugs. Everything from aspirin, potassium three times a day to warfarin, a diuretic, a beta blocker and a couple of long unpronounceable heart drugs. Fourteen in total. He’s seen a lot of specialists, home nurses, respiratory techs, physios and so on.

The second question he gets asked by all these practitioners (right after “How are you feeling?”) is “What drugs are you on?” There is, of course, no way he can remember what drugs he’s on, but thanks to his local drug store and some cutting and pasting over the kitchen table, he has a list, which he now carries around from appointment to appointment.  Of course, the list changes from time to time, as his family doctor, cardiologist, respirologist or some other caregiver changes the mix.

I’ve asked various caregivers, occasionally, “Can’t you get a Pharmanet profile?”  Since all these folks are connected with a major hospital, it should be pretty easy to look my friend up and get an accurate list of what he’s taking. The answer has always been negative. Too hard, don’t know enough about it, not available here, drug list would be too long. For better or worse, no health care professional over the past five months has checked his Pharmanet profile, as far a I can tell.

Another friend, a semi-distant relative, also a heart patient, aged 80, changed his drug mix a month ago. Things didn’t go well, and he was at Emergency on a recent Saturday morning. “When did you start taking the new drug?” “Well, it might have been three weeks ago—no, wait, it was only last week. Oh, I’m just not sure.”

At a certain age, our short term memory slows down and we fumble easy questions. A quick check on Pharmanet would have told the story immediately. The good news is that he went to the drug store, got his list of drugs, sent it to the family doctor and he stopped the new prescription, changed another one and all is well.

Pharmanet for the medical practice has been around since 2003. We’re deeply engaged in making access to Pharmanet available to doctors and hospitals across BC. Hospitals are very keen; Interest from physician offices and clinics is minimal. We don’t understand that. While there’s a bit more effort involved (medical practice access costs a few dollars each month, and doctors are required to gather patient consents), surely the benefit of knowing what drugs have been issued to the patient out-weighs the small cost.

Richard Alvarez, head of the national Canada Health Infoway project ($1.8 billion over six years for health IT) was praising BC’s system this morning in a keynote at the eHealth conference in Quebec City.  But what good are these systems if people don’t use them?

Comments welcome, as always.

Side effects lead to ER visits

Study finds 12 per cent of patients rushed to VGH have adverse reaction to medications
Pamela Fayerman, Vancouver Sun
Published: Tuesday, June 03, 2008

Twelve per cent of patients who rush to the emergency room at Vancouver General Hospital are there because of adverse effects from medications, according to study findings being published today in the Canadian Medical Association Journal.

The 11 international authors of the study said patients with medication-related complaints are more likely to be admitted to hospital beds after they've been seen in the ER and occupy those beds far longer than others, a result the authors described as "striking."

The study estimates that 70 per cent of such visits are preventable through better prescribing, dispensing and monitoring of patients.

"We've proven in this study that we've got a problem in the health care system with patients who experience bad effects from medications and we have to figure out how to reduce those problems," said lead investigator Dr. Peter Zed, who was working at VGH during the study but is now at the Queen Elizabeth Health Sciences Centre in Halifax.

"The solutions will involve better communication among doctors, pharmacists and patients," Zed said in an interview. "Simply handing out a pamphlet at the pharmacy that lists all the potential side-effects doesn't work. Patients don't read them or they don't understand the information."

Problems stemmed from a variety of issues including patients being prescribed the wrong drugs, given wrong dosages, allergic reactions, interactions between drugs and patients not following instructions for how or when to take their medications.

A future study will help determine the best approaches to avoid such problems, Zed said, but plans by the B.C. government to broaden the use of electronic health records will help reduce medication errors. The new record-keeping system will improve communication among doctors, pharmacists and other health providers as well as provide information about the best drugs to prescribe, drug interactions and proper dosages.

About 180 patients a day go to the ER at VGH, B.C.'s biggest hospital with 955 beds. Slightly more than 1,000 patients were randomly selected during a 12-week period from March to June, 2006. In that period, a total of nearly 15,000 patients went to the ER.

Of the 1,017 patients included in the study, 122 -- or just over one in nine patients -- were at the hospital because of adverse drug-related events, defined as "unfavourable occurrences related to the use or misuse of medications."

No one died from medication effects, but those who were admitted to hospital stayed a median of eight days, compared to 5.5 days for those who were admitted with non-medication problems.

Health Minister George Abbott said in an interview the study points to the need for "continuous improvement when it comes to misuse, overuse and abuse of drugs."

The province plans to establish a patient safety and quality council to reduce adverse events, promote transparency and identify best practices to improve patient care, Abbott said.

A total of 179 medications were implicated in the 122 drug-related visits to ER. Nearly 16 per cent of cases were mild (no treatment required), 75 per cent were moderate (treatment and/or hospital admission required) and just under 10 per cent were severe, with life-threatening symptoms potentially resulting in permanent disability.

The mean age of patients in both arms of the study (drug-related complaints and non-drug) was about 50 and gender was also about evenly split.

Adverse drug reactions are often tricky to sort out, and the authors said that is why many patients have to be admitted to hospital beds for monitoring and resolution of their concerns.

Central nervous system medications such as opioid painkillers, antipsychotics for those with mental health issues, sleeping pills, and antidepressants were the types of drugs most likely to cause problems.

Cardiovascular drugs were next and then antimicrobial drugs for infections. The study found that more than two-thirds of patients with medication problems could have avoided their ER visits with better prescribing and better comprehension of how to take the drugs.

Patients in the study were interviewed to determine their primary complaints and to get their health and medication history, and allergy status. A month after they were discharged from hospital they were called by researchers about their progress and outcomes.

Sun Health Issues Reporter
pfayerman@png.canwest.com

If you have a comment, please email us at info@medinet.ca

Taking New Patients?

Vancouver Canada

A funny thing happened to one of our staff the other day.  After a number of years attending the walk-in clinic around the corner from the office, she decided to see if she could hook up with a regular family doctor. The clinic had a sign in the window, saying that a new doc was coming in and would be taking new patients. So far, so good.

When Sue (name changed, of course) called, the office person said that the doctor had a questionaire for prospective new patients, so if Sue would just fill out the form, she would pass it along to the doctor.

Odd – she's been attending the clinic for over ten years.  The chart must be pretty thick by now. Sue wondered what was on the form. Turns out it was the usual medical history, childhood diseases, hospital visits, chronic conditions.  She answered all the questions, returned the form and waited.

Nothing happened, so she phoned over to see when she could come and meet her new doctor.

Turns out the doctor rejected Sue, on the basis that she didn't seem to have the proper attitude.

Sue had answered several of the questions on the form with "See chart". Her idea was that the chart was there, that it would probably be more accurate than her recollection, and that if the doctor wanted more information, she would let Sue know when they finally met.

Seems that the new doctor thought Sue offered insufficient respect for her process. We assume she was looking for patients that were not too sick, that would be easy to manage, that would respect her opinions, follow her recommendations, accede to her demands.

Now the interesting question: Is this okay? Doctors attend publicly subsidized medical schools, are paid through our tax system, and certainly fill an important role in the health care system.  We all need good family doctors, even if we’re not in good health.

Walk-in clinics serve a useful role in the system, especially at odd hours when most family practice offices are closed. Hospital emergency departments are not the best place for the kinds of things that walk-in clinics handle on a routine basis. At a time when more of us are working at times other than nine to five, seems to me we should support these street-corner operations.

That being said, if someone hangs a up shingle saying “Taking New Patients”, it ought to be without discrimination. Walk-in clinics have been accused of practicing easy medicine, of serving as a prescription renewal service, of pushing the hard work onto the hospitals. Is this true? Maybe not, but one doctor, at least, is living out the bad reputation.

jrc

To comment, send a note to jrculter@medi.net

We're all green at Christmas!

Vancouver, Canada
Friday, December 20, 2007

As always, it's good to see the churches rallying around the popular issues of the day.  The headline in Thursday's Vancouver Sun is "IMPOSE A CARBON TAX, CHURCHES URGE GOVERNMENT", and "Saving planet a sacred duty, Anglican and United officials say." No doubt the government (provincial, it seems) will listen closely to this helpful plea, and wonder again why, when we can't manage our own affairs, we're so free with advice.  If you think about it for a moment, you'll see that church buildings are the worst offenders in the country. We specialize in energy-expensive, drafty, old and inefficient architecture. not much of an example if we actually wanted to do something about the problem rather than talk about it.

My wife, Aldyen Donnelly, has been taking up room on the Op-Ed page of the Financial Post lately, in an interesting dialog with Mark Jaccard, a prof from SFU.  Naturally the fuss is about climate change and government policy.

Dr Jaccard is a carbon tax advocate. His idea is to stick a heavy tax on things like gasoline, heating fuel, industrial energy consumption, so that people and businesses will be motivated to use less, or maybe find some greener form of energy. Aldyen points out two problems: carbon taxes are highly regressive (which means that low income people suffer the effects more than high income people) and that as a general rule, taxation or raising prices doesn't seem to do much to change people's behavior.

To the problem of regressive taxation,  Dr Jaccard offers that governments will collect the carbon taxes and wisely use the funds to reduce income taxes for the poor and otherwise correct the imbalance the carbon tax creates. Of course, there is some history around specific-issue taxes in Canada. Anyone remember when we started a gasoline tax and the funds were to be dedicated to road improvements?  (That was a $4.7 billion item federally last year.) Or the various provincial and national lotteries that were to benefit sport and culture? Generally governments have a nasty habit of taking taxes into general revenue, and doling them out according to the needs of the day. But it also costs a lot to run money through the government tax collection process and then back out the door as grants or subsidies.  Maybe up to 30 percent is lost in the shuffle.

A large issue around home heating, which matters a lot as we move outside the Lower Mainland, is that low income people are the least able to make the changes to their houses or apartments to make them more energy efficient. Aldyen argues for a national "fix up the housing stock" fund to allow people to improve their dwelling places.

To change people's behaviour, Aldyen argues that raising prices, through taxation or any other system, actually doesn't do much.  A good personal test might be to sit down and compare the driving you do this week, with gas at $1.20 a litre, against the driving you did this time last year when gas was at 90 cents.  I'm guessing you're spending about the same time in your car. Not much change in behavior after a 33 percent increase.

Aldyen's message is that governments have the power to change all this by simply making regulations as needed. Car manufacturers are obliged to maintain a fleet average of so many miles per gallon. If they don't meet the targets, they can't sell the cars. And those regulations, of course, are the reason that fuel efficient cars actually exist (otherwise I'm pretty sure we'd be even more overrun with SUVs and the like.) There are many other places in the system where simple regulation can get the job done, with certainty and with care, under appropriate regulation of industries and consumers.

Beyond that, we are in a world of perverse incentives.  The Alberta tar sands project is quite useful if you're looking to produce more gasoline, but it's highly subsidized and a huge contributor to climate change. The Americans hugely subsidize the production of ethanol from corn, which isn't a very good way to make ethanol anyway, and it's driven up the price of corn, a major feedstock for the rest of the agricultural economy. And so it goes.

It's a wide and important discussion, with huge potential impacts on our lives and the lives of our children.  My hope is that those of us in the church will do what church people are supposed to do (other than offer up well meaning petitions and press releases). We can pray for those in our governments to be wise and thoughtful. We can model good behaviour by fixing up our buildings, our cars and trucks. We can engage with the discussion from a place of knowledge, by trying hard to understand the economics, by dealing in hard facts, and asking those with grand ideas to tell us how they're going to work out in real life.

Probably the most important, start to understand that solving the problem is going to take sacrifice. Major industrial enterprises are going  to close. Jobs will be lost. Food will cost more. Driving will cost a lot more. Christians understand sacrificial life, albeit somewhat theoretically most of the time. But now it's time to get down to it.

Everyone gets that we have a problem, even government. Time to start working on solutions.

jrc

Paper everywhere!

Wednesday, October 3, 2007

Medical offices doing business with Vancouver General Hospital have had an interesting experience recently. For reasons known only to management, VGH decided that it would like to have two firms competing to deliver its lab reports to physician offices.

Vancouver General has been a Medinet client since 1991. As far as we can tell (and we have the nice letter to confirm it) we do a pretty good job of carrying lab results from the hospital to our client offices. While much change is on the horizon, there doesn't seem to be a pressing need to change things around, at least until the new major projects come on stream. But change we have, for better or worse.

No question we do some things differently from our competitor. Medinet is designed to deliver lab data quickly and conveniently, so that it can printed and stuck into the patient chart or inserted electronically into the office EMR system, if there is one. We don't allow you to decide whether or not to print reports. Reason is that our sending lab clients want to make sure that everything they send is charted, so we designed our software to enforce that.

And for a long time, we didn't offer a look-up system, so if someone lost a result, it was a nuisance to get another copy from the lab.  Happily, we've just introduced our LabTrack product, which allows all Medinet users to search back through the system by patient name or PHN and pull up old reports.

So we think the playing field is pretty level.

Back to Paper Everywhere! When we first heard about the decision to bring in our competitor, after we got over our surprise, (no one had indicated that this was in the cards) we wrote and asked for details. The deal was that Vancouver Coastal would "provide notification to every physician that is affected that they now have a choice of delivery . . ." So far so good.  But two days before we got the letter, VGH started sending all its reports to us and to our competitor. Duplicates and paper everywhere!

It's a larger problem than it appears. Seems that our competitor isn't able to carry anatomical pathology over its system. So offices were having just a part of their stream from VGH duplicated, and now, even if they want to use our competitor, they have to check through all the reports each morning and separate out the anatomical pathology results to make sure nothing is lost.

We don't know what happened. The VGH letter said that, "over the next two months VCH will contact our affected physicians and inquire as to their preferred reporting route."  and "As feedback is received, VCH will begin delivering laboratory reports . . . ." But it all started last Monday morning!

Our people got lots of calls, asking for an explanation of the duplicates, and wondering what had happened to our easy, fast and convenient delivery service. Once we figured it out, we got a letter of our own out. It provides a way to turn off the duplicates. So far, we've had over 250 requests, which we have forwarded back to VGH. We're not sure whether the lab is acting on this information, but we sure hope so.

We've heard on the street that the duplicates are going to continue for another week. We're not sure why, and we hate being caught in this process. At the moment, we're not hearing much from the lab at VGH, but our hope is that they can modify their system a bit, and get some control over the reports they're shipping out.

More news when we have some.

jrc

                                                   

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Welcome!

Monday, August 6 2007

Welcome to  new part of our web page. We thought that since we seem to get involved in lots of conversations about new developments in our game, we should pass them along to you. Some things won't be new; others might be.

For those who don't know us, Medinet has been around since 1989, when we were asked to figure out a way to send lab reports electronically from BC Biomedical Laboratories. We set up a pilot project, got tee shirts and some third-party software, used the very early email network created by the long distance phone carriers, and started in business. We soon added the BC Centre for Disease Control and what became MDS Metro. In fact, Don Rix, recently appointed to the Order of Canada for his innovative spirit, was one of our earliest supporters. Anyway, we added service for most of the major hospitals in the province, and found ourselves with a workable business.

Things got a bit tight in the late nineties, when our two private for-profit lab clients decided to start up in competition with us. We were left with what are now the health authority hospitals across the province, and that has proved to be an interesting and rewarding group of clients. So, we carry data for Vancouver, Lions Gate and St Paul's hospitals in VCHA; Royal Jubilee, Victoria and Saanich hospitals in VIHA; and Royal Columbian, Eagle Ridge, Ridge Meadows and Burnaby hospitals in Fraser Health. As well, we still have our first major lab, BC Centre for Disease Control, along with Women's and Children's Hospital in PHSA.

We carry about 2.5 million lab reports annually for these sites, to around 7,000 users in 2,000 offices and clinics. Our clients are scattered across the province, from Victoria to Ft St John, from Haida Gwai to Cranbrook.

The late nineties also brought us the longest running pilot project in history, with the advent of physician access to Pharmanet. The pilot ran over five years, before it finally was approved for use in doctors' officers around British Columbia. We had the major portion of the 100 pilot sites, and we have ended up being the main provider of Pharmanet access to physicians and hospitals. The service comes in several flavours depending on who you are and where you work. We are finally certified for all possible options, we think, until the ministry changes things.

In the meantime, we can offer Pharmanet access to the physician office (Medical Practice), to emergency (Emergency Department), to general locations inside hospitals (Hospital Access) and to hospital pharmacies (Hospital Pharmacy Access). Needless to say, the paperwork requirements are considerable, but we've got it figured out now and can get you going fairly quickly.

Like most people in our field, we're looking ahead to the new environment -- the result of the feds spending $1.7 billion on health information technologies. It would be nice to imagine that some of that might trickle down to us, but for the moment, it's business as usual.  We'll have more to say about all this in coming weeks.

jrc

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