Friday, May 25, 2007

Dealing with structural and mechanical failures

What a week! I returned to work on Tuesday after the long week-end, only to be greeted by a truly awful smell in my back closet. It turns out that a sewage pipe in the condominium building above my office had leaked. I have been worried about water leaks for a long time because we are at the bottom of a condo. My routers and SOFA (Small Office Firewall Appliance--the blue box that SSHA sends physicians) are located on a shelf in the closet. I don't think they'd appreciate being exposed to a load of crap.

We built a canopy above the equipment several months ago; this saved the day. The building manager sent a plumber and cleaners over pretty quickly. I guess it could have been worse; replacing all the routers would not have been easy. I could be up and running with my back-up internet line and VPN access pretty quickly; the problem would have been the SSHA equipment--it took a long time to arrive when we first ordered it. I wonder if they have expedited delivery for problems like this, where practice continuity is at stake.

My partner was away this week. I saw one of his patients and had to talk to him about further investigations. While talking, I had to flip through the pages to look for an old XR; I could not find it. I am getting used to the organization and speed of the EMR--dealing with a paper chart is becoming frustrating.

We also had a paper-side failure a bit over a month ago: our fax line went dead (I think my office is jinxed). It took Bell three days to come and fix it. Of course, all the XR reports and consult notes come by fax; I think of the fax as the main paper-side (or non-EMR) external communication conduit. One of the issues with fax is that people don't always look at the verification when they send something, to make sure that the fax went through successfully. We notified the hospital, but I'm sure we lost some data.

I order Diagnostic Imaging via the EMR, unless a proprietary form is required (example: MRI). The EMR tracks outstanding DIs. I had a look at those, to make sure that there was nothing that I was truly worried about. While I was at it, I put alerts in the charts of all patients with overdue DIs. A couple of patients have already told me they never went--mostly bone density XRs. I gave them a duplicate of the req. We called the hospital for 3 patients, and they faxed over the results; these would have been lost without EMR tracking.

We had another medication problem this week, for Avandia. I have four patients on this drug. I had a look at the original article, and our clinical pharmacist e-mailed some very helpful information and analysis to my group. I've reproduced the letter that went out to my patients below; I'm getting used to this process! As well, I installed the letter and set up the Avandia mailing list for one of my FHN colleagues in another office, remotely, so I know this can be done. We can think about managing this as a group, with a common letter and mailing, in the future.

Here is the letter:

Dear ....

I am writing you this letter because you have been prescribed a medication called Avandia (or Rosiglitazone) to lower your blood sugar.

A study reviewing the effect of Avandia has just been published; it found that patients taking this drug had a somewhat higher risk of having a heart attack than patients who were not taking the drug. About 4,700 patients would have to take this drug for 6 months to 4 years to cause one extra heart attack. The full study can be accessed at

Diseases of the heart and blood vessels are the commonest cause of serious illness and death in people with diabetes; preventing this is a very important part of your care. This is the reason why I prescribe aspirin, cholesterol medications and blood pressure medications.

Because of this report, I am asking you to make an appointment to see me to discuss this drug. Several other medications for blood sugar have been found to be safer; I would like to review your medications with you.

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