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October 28, 2010
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.
Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.
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October 13, 2010
For most of my career as a family doctor, I kept track of my patients' health histories by scribbling hand-written notes in a paper chart. For a healthy child, I'd include dates when vaccines were given; for an adult with, say, diabetes, I'd make sure to jot down a recommended schedule of blood and urine tests as well as foot and eye exams. A majority of primary care physicians, in fact, still use this kind of tracking system—despite research suggesting that these handwritten flowsheets aren't just inefficient, but extremely vulnerable to errors. Some say the solution lies in simply switching to electronic medical records.
After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.