Work Flow and Clinical Decision Making, Part II

In our last column titled “Work Flow & Clinical Decision Making, Part I: Emulating your workflow and incorporation of ‘Best Practices’ into your EMR system,” we discussed that there is a groundswell of legislation to force doctors to not only computerize their practices, but to have a system in place that will drive their evaluation and treatment and derived from evidenced based guidelines.

In this issue, we will discuss why it is becoming increasingly difficult for the pain doctor to stay on top of state guidelines and how EMR systems will inevitably incorporate such guidelines to drive clinical decision-making; in essence, helping dictate how you practice. We also discuss that, because of the necessity to prescribe pain medication, you will need to have a detailed protocol to help ensure that you are safely prescribing, as well as documenting the necessity for such prescriptions. In the very near future, this will be linked into a national drug database to minimize over-prescribing and drug-to-drug interactions.

Concomitant Issues

Yes, it has been all over the news: the human cost of medical errors is high. Based on the findings of one major study, medical errors kill some 44,000 people in U.S. hospitals each year. Another study puts the number much higher: at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. And a recent study found that one in every four medications dispensed in several hospitals involved some degree of error. The high level of prescription error caused the adoption of the Medicare Prescription Drug Improvement, and Modernization Act of 2003 (MMA). In essence, the MMA sought to computerize doctor’s prescriptions and have them electronically linked to pharmacies and, in the process, provide checking systems to minimize errors.

The fact is that the majority of medical errors do not come from doctor mistakes, but in the manner of practice and how the health care system is currently organized or . . . disorganized. Unfortunately, you are responsible in your clinic and can have legal exposure if you are not careful in how you document your patient visits. You need to set up “patient alerts” (allergies and such) and have prescription audit trails. Since you are a pain practitioner and deal with narcotics, this is especially important.

Some Reasons for Prescribing Mistakes

• There are too many drugs that sound the same. The abbreviations may be similar and there are different names for the same type of medication.
• Confusing labels and packaging.
• Numerous studies have documented errors in prescribing medications, dispensing from pharmacists, and incorrect utilization by the uninformed—or worse, addictive—patient.
• Full-strength drugs need to be diluted and/or are mixed together with other drugs to make pain medication cocktails. This makes it very difficult to check for drug-to-drug interactions and patient allergies.
• Illegible writing in prescriptions, as well as in patient medical records, can cause improper prescription for which a patient has a known allergy.
• Medical knowledge and technology changes make it very difficult for a doctor to stay abreast of the changes.
• Patients may go from clinic to clinic and be treated by several doctors and obtain prescriptions unknown to you.

Significant improvements have been made in some hospitals since the Institute of Medicine released a landmark report in 2000 reporting the medical error statistics. However, change is not happening fast enough and over the past few years, according to the Journal of the American Medical Association (JAMA), the death rate has not changed much. Slowly, systems are being put in place to better report and make doctors accountable at the private practice level.

The Pain Factor and Additive Opiates—How Do You Keep Up with It All?

According to the American Academy of Pain Medicine (AAPM), over 75 million Americans live with serious pain; 50 million have chronic pain; and each year, 25 million experience acute pain because of injuries or surgeries. Forty-five percent of Americans seek care for persistent pain at some point in their lives. There has been, and will continue to be, a shortage of anesthesiologists and other pain practitioners projected over the next 10 years. Thus, you need to be very organized and have a system in place to guide and keep you on track in dealing with the many pain patients.

Too often, patients with abusive use of narcotics are simultaneously seeing several physicians to feed their habits. Sometimes patients abuse cocaine, alcohol, or other legal and illegal substances in order to maximize the effect of their narcotic medication. You will get patients that will request narcotics for uses that are not appropriate, such as to relieve anxiety, depression, or insomnia.

There have been studies that have shown that pain practices routinely under-prescribed opioid analgesics for fear of state board disciplinarian action. An important consideration is that clinics must inform patients of their right to effective pain care. If your facility does not do so, you could lose your accreditation. Thus, because you are a pain management doctor, you may have to provide pain care to patients that require narcotics and, because you deal with narcotics, you will have to cover yourself with detailed documentation and patient monitoring systems in order to avoid inadvertently supplementing a patient’s potential drug habit. It can be a double-edged sword.

The fact is that the failure to be aware and comply with state medical board requirements could lead to disciplinary action or pain clinic closing as has happened in some parts of the country.

National All Schedules Prescription Electronic Reporting Act (NASPER)

On August 11, 2005, President Bush signed the NASPER prescription drug abuse legislation into law. The new law promotes improved patient care by promoting quality pain relief. At the same time, it establishes greater accountability on the part of health care providers. It creates a national electronic data bank for doctor monitoring of Schedule II, III and IV controlled substances.