Treat the patient, not the record — Or, how I learned to stop worrying and love the brown bag of pills

On my ICU rotations as a medical resident, a fundamental teaching point from our professors was to never be fooled by all of the flashing data about your patient on the various bedside LCD screens. Always verify the data. Your primary point of reference should always be the person lying in the bed, not just the data being seductively presented all around them.

Oxygen saturation low on the monitor? Start by listening to the patient’s breath sounds. Pulse rate zero on the EKG monitor? Put your hand over their wrist or neck and palpate it yourself. And so on.

Today the ubiquity of EHR screens in our clinical practice has led to a new problem – treating the patient’s record instead of the patient themselves.

One area of particular concern is in medication reconciliation. Some EHR systems are able to auto-compile a list of medications from claims data or e-prescribing sources. These data sources can be incomplete for a variety of reasons.

Many clinicians see this as a time saving feature and it certainly has merit as an auxiliary data source when the patient is incapacitated or a poor historian. But as with all electronic data of unknown quality or completeness, it cannot be trusted without verification from the patient sitting in your exam room.

In developing MedSnap ID, this was the primary goal of our design – to capture the patients understanding of their medication regimen and at the same time verify possession of the correct pills. MedSnap’s enhanced medication history taking process starts with the patient as the source of truth, and our technology expedites its conversion into electronic information.

No matter how sophisticated technology becomes, we must always begin with a focus on the patient and verify our assumptions before proceeding with a course of treatment.

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