Chart review

Chart review is one of my occasional clinical responsibilities.  The charts I see overwhelmingly document good quality medical care. Last week I saw a chart that gave me pause. 

Mrs. A was a 66 year old retired bank teller who was brought in by her husband for ‘follow up confusion and meds.’

Chart review revealed the following. Mrs. A was a hypertensive insulin-dependent Type 2 diabetic whose BP and DM had been well controlled until about 3 years earlier, when she started missing appointments for lab and follow-up. At this time, concerns were also raised about whether or not she was taking her medications properly (running out too soon, not refilling them, not understanding which medication was for which condition) and her BP was intermittently poorly controlled and her A1c crept from the < 7.5 range to consistently over 10.  She had been lost to follow-up for about a year. At the most recent visit, 7 months earlier, her A1c was 14 and her BP was 162/98, she had run out of insulin and was not taking her BP medication. Between that visit and the current visit (which I had been asked to review) there were several missed appointments and attempts at phone contact, with multiple notes documenting concern about mental status and ‘compliance’ with care.

At this visit, the patient was noted to be confused, unable to give appropriate answers to questions, with good long term memory but badly impaired short term memory. Her husband noted that she got lost often, he only let her drive locally and he called her on the cell phone to check on her when she was out.  She was noted to have poor hygiene, with a strong odor of urine. Her A1c was 12.4 and her BP was 174/96. She was not checking home sugars. Her diabetic foot exam was normal. Her fall risk assessment and depression screening were done.  She was given a shingles vaccine and colonoscopy and mammogram were recommended, which she refused. Pneumovax was offered and declined. Her insulin prescription was refilled. She was given a follow-up appointment in 6 weeks ‘to further discuss preventive protocols and review DM, mental status.’  Her abnormal mental status and elevated BP were not addressed, and although dementia was on the problem list. Nothing was documented about discontinuation of driving. 

My chart review summary was:

  • Dementia mentioned, appears to be worsening, but was not evaluated.
  • Dementia management options and impact on chronic disease management not addressed.
  • She should not be driving.
  • Her BP needed to be treated.
  • Her insulin administration needed to be done with supervision.
  • With steadily progressive dementia and poorly controlled chronic illnesses of diabetes and hypertension, she probably has a life expectancy of < 10 years, so mammography and colonoscopy are probably not warranted.

The clinician who saw this patient works in a good quality primary care office in a nearby community. I have known him since he was a resident on our local teaching service. He is bright, well trained, conscientious and compassionate.   When I discussed the chart with him, he confirmed my suspicion: he had been focused on meeting his institution’s requirements for meaningful use (MU), and metrics driven by their accountable care organization (ACO) and payors. Actual care of the patient had been lost in a sea of yellow button protocols and required screening/prevention/quality workflows. He said: “We need a yellow button to remind us to ask what this individual patient needs most today.”

This was, of course, an extreme example.  In a smaller way, the same thing is happening quite consistently at most primary care visits in most primary care offices. Lists and protocols are replacing the patient as the focus of care. Thinking is becoming secondary to compliance. The tail is wagging the dog.

 


 

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