I recently accessed a patient chart within TouchWorks and noticed that the patient had 25 active medications listed! On perusing this list, I saw at least three different prescriptions for the same antibiotic over a two-year period. I also noticed a couple of prescriptions for the same analgesic. Some of the prescriptions were originally entered in 2006.

This got me thinking about the whole patient-centric chart and the issues about maintaining up-to-date medication lists, problem lists and allergy lists.

All For One, One For All
The patient-centric chart in TouchWorks is obviously a new way of practicing for all of us. We no longer have in place the traditional pediatrician's chart, orthopedist's chart, gynecologist's chart or the primary care physician's chart.

We are now all sharing the same chart in a patient-centric environment. We are all continually adding to this patient centric chart and are all equally responsible for maintaining and updating the healthcare data that lives in this system. It obviously takes time to adjust to this new way of organizing patient data and sharing information between different practitioners. It is a totally different way of practicing medicine and introduces us to a more team approach to patient care.

I would like to make some suggestions as to how we as a team of practicing clinicians might go about keeping all this information correct and up-to-date within the TouchWorks electronic health record system. There are several well documented workflows that can help with keeping the data current, and as a consequence, improve patient safety.

Firstly, let us look at the issue of the patient's medications list. You may notice when accessing the medication list there are three different views available. These views are the active medications list, the past medications list and the combined list. Once a patient has stopped taking a particular medication, it needs to be moved to the past medication list.

Automating Medication List Updates
This is easy to do. Check the END DATE box when prescribing a new medication.

By clicking this box, the particular medication will be moved to the past medications list automatically on October 4, 2010 in example below.

This is a very efficient way to keep the medication list up to date. If you instruct your medical assistants to enter prescriptions, then you may want to train them in this functionality.

Removing Meds Manually from a List
If you come across medications that have been prescribed by another physician on the system, and you are certain that the patient is no longer taking these medications, you can move them to the past medications list.

Hit the DISCONTINUE button.

If you routinely have your medical assistant start a note, then I recommend you train your assistant to ask the patient which medications they are actually taking and then update the electronic list accordingly.

Clicking on the end date box is particularly useful if you are prescribing a single course of medication such as antibiotics or analgesics. You may not want to check this box if you think the patient is going to be taking the medication long-term.

Keeping the medication list up to date is particularly important from a safety perspective. The Clinical Decision Support (CDS) that is built into the TouchWorks system will read the active medication list as though the patient is actually taking all the medications listed. Therefore the drug-to-drug and drug-to-allergy interactions will operate as if these medications were active. Once the medications are in the past medications list, they will not be part of the CDS reminders and alerts.

Another issue that we face when dealing with a shared chart scenario is that of maintaining a current problem list. From talking to a lot of physicians, it appears that the primary care physicians are spending an inordinate amount of time trying to maintain and update the current problem list. However, there are a large number of specialists on the system who are not actively populating this list.

This makes it very difficult for the primary care physicians (or any other physicians, really) to obtain an accurate view of the patient's current health status.

Often times the patient will have undergone a surgery, for example, and this is not documented in the problem list. The primary care physician and will then have to hunt through the chartviewer list of documents to find a specific diagnosis or surgical procedure for example. This will then have to be entered manually after the fact.

Updating Resolved Problems
It is also good practice to check the problem list for complaints or conditions that may have resolved and mark them as such. These may be problems that were entered by another physician (for example, an ankle sprain in 2006 which is obviously now healed).

Simply highlight the entry and click on Resolve. This will now place the condition in the patient's past medical history.

This can also be done by a medical assistant prior to you as a clinician seeing the patient. Please note that if a condition is listed as an active problem than it will be part of the Clinical Decision Support built into the system.

An example of this would be a diagnosis of liver disease in the problem list and a practitioner wanting to prescribe Tylenol. In this particular scenario a warning box would appear asking the prescriber if they want to proceed with the prescription or not. If the condition is made Inactive or Resolved than it will not take part in the appropriate reminders or alerts generated by the system.

In the end, we are all responsible for maintaining and updating patient data. The effective use of the TouchWorks electronic medical record system revolves around a team approach. If the data is accurate and up-to-date, we are all better informed, and that has a positive effect on patient quality of care and enhances patient safety.

If you have any questions or comments on this topic, please do not hesitate to contact me at arawlinson@btmg.com.


Adrian Rawlinson, M.D., is the Medical Informatics Director at Brown & Toland Physicians. Reach him at arawlinson@btmg.com.