A New Kind of Reconciliation

"I need all my medicines."

This was the last line of my last patient of the morning, the hand-on-the-doorknob, after a packed schedule of complex patients with complicated issues -- you know, the usual. This after she had started out our long, interpreter-assisted visit with "I have so many things I need to talk to you about today."

These included a multipage form for her preoperative clearance for cataract surgery scheduled for 3 days from now, an issue with a dentist she did not like, some outside records to review, as well as a request for me to go over all of the labs done by her multiple specialists that she'd seen earlier in the week to tell her what they all meant.

As we were finally wrapping up, after she had said my medicines are all the same, you have them there in the computer, she told me she needed refills of "everything."

I thought this was strange, since she had just been seen in the practice a few weeks earlier, and all of her medications had been sent to her pharmacy with multiple refills.

Was it an insurance issue? Had she forgotten? New pharmacy? Electronic failure?

One of the nice things about e-prescribing is that I can, well after a visit, sitting safely in the confines of my office, cup of coffee by my side, with a few clicks of a button, refill all meds.

And an easy out is just to highlight them all and click the refill button.

No muss, no fuss.

But, in a move I would later realize created a lot more work for myself than I had anticipated, I gave her the flu vaccine, put in her referral for oral surgery, sent her for her x-ray, and let her go home.

About half an hour later, sitting at my desk, I opened her chart and went through the medication section, reviewing what she was on and what she might need refills for, getting ready to confirm that I had done the all-important medication reconciliation.

There, hovering tantalizingly above the medication section, was the always surprising, always interesting, and always complicating, bright red warning: "New medications from outside sources are available for reconciliation." Preceded by double exclamation points, so it must be important!

It's amazing what we discover when we click a button.

Sometimes we can seem like a magician to our patients, by piecing together a group of medications and coming up with a diagnosis on our own.

Topical metronidazole: So, have the medicines from your dermatologist helped the rosacea?

Azithromycin and benzonatate: Did that bronchitis clear up?

A gallon of polyethylene glycol 3350: How did the colonoscopy go?

And sometimes, what hits us in the face is a wave of outside medications, totally unexpected, totally confusing, totally not what we think our patient is on.

That was the case with my patient today, a long list of medications, filled most recently nine days before our visit, including a different blood pressure medicine, a different insulin, high-potency topical steroid, high-dose proton pump inhibitor, and on and on and on.

Faced with this in the office, I would just say, are you taking these? Is someone else managing your diabetes?

Sometimes, patients look at us like we're crazy, they don't even recognize those medicines, must not be them, and this ends up being some electronic hiccup, a ghost in the machine.

Sometimes it can be a useful functionality.

One time recently, a patient asked for a panoply of medicines for attention deficit hyperactivity disorder, and through the reconciliation function and the state controlled substance registry we were able to find she was getting them from outside providers, most recently the week before.

Double dipping, and more.

One new patient seen by a resident, at the end of the visit, told her that she had migraines and needed a refill of the Tylenol with codeine #4, the only thing that worked, and when the resident asked about drug use she reported, sheepishly, that she had "once smoked a little pot," followed by a giggle.

When the state registry and the reconcile medications list, as well as the review of multiple admissions to our own hospital for detox revealed a complex polysubstance abuse history that was much more than the patient had let on to, we went back to discuss the issue with her, at which point she said, "Oh well, I tried," got up, and walked out of the practice.

But what happened with my patient seemed to be something different. This was my patient of nearly 2 decades; this wasn't somebody I thought had any reason to deceive me.

So I called her daughter, who she'd asked me to call anyway to make sure we haven't missed anything, and because she wanted me to go over her blood test results with her daughter since she didn't always understand them, even with the translator. When I mentioned the issue about her medicines to her daughter she said that in fact her mother "has another doctor she sees sometimes, on 96th Street."

Now, it never really occurs to me to ask my patient if they have another doctor managing the medical problems I think I am managing, but I have to say, it never surprises me when I discover that they do.

People tell me all the time about their "other doctor" -- sometimes it's someone they see right near their home when they have a cold and can't get in to see me, sometimes it's just for that good old second opinion, which is totally fine.

But taking a whole other set of medicines for high blood pressure, diabetes, asthma, and for a woman with as many complicated advanced medical problems as she has, is just a recipe for disaster.

If I had just clicked "refill all," and she ended up doubling up on all the medicines for all of her conditions, well, no telling how badly her simple cataract procedure could have gone.

Blood pressure of 50/nothing, sugar level when fasting for the procedure in the 30's, unknown interactions with anesthesia.

So for once, the electronic health record may have actually done some good, catching something that can help prevent drug-drug interactions, or complications that were unforeseen based on what I knew, what I thought I knew.

These systems give us insight into the care our patients receive beyond the boundaries of our office walls. While they often are a lot of noise, duplicates generated by pharmacies and insurers feeding data into the system, sometimes they can open up our eyes to things that are happening in the lives of our patients that we never even considered.

Something else to reconcile.

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