A Stubborn Rash: When Doctors Don’t Communicate

Paul Ploetz has a pulmonologist and a cardiologist and I am his primary care doctor. His two specialists work for the same hospital system and I work for a different organization. His specialists send me their notes and I can also look them up on Maine’s statewide database. My organization’s notes aren’t there, at least in part due to the fact that our EMR vendor charges big money for uploading notes to Maine Health InfoNet.

Paul had been increasingly short of breath. His pulmonologist didn’t think this was related to his COPD, so he prescribed a two week trial of furosemide.

I saw him toward the end of that, and he was itchy and had a rash that looked like scattered excoriations and was only located in places he could reach and scratch.

I suspected he had become allergic to the furosemide, which is common and can cross react with sulfa allergy. I marked his chart with allergy to furosemide. I told him to stop it and prescribed something for his itch.

Two weeks later he came back and told me the rash never went away completely. Two medicines and a couple of creams later he was frustrated with my inability to cure him. So was his daughter-in-law.

I made sure his dog wasn’t scratching. I looked as his other medications, none of which seemed likely to be causing his rash.

On a hunch, I clicked the “PBM” button on top of his medication list. It displays what medications have been billed through insurance, Pharmacy Benefit Management. For clinicians, this is read-only; I can’t enter a stop order there.

There, with a date about two weeks after I stopped his furosemide, was a listing for the same drug – this time prescribed by his cardiologist

I showed him this. He shrugged. He wasn’t keeping track of what pills he was taking.

I went back to his cardiologist’s notes. Sure enough, buried in a multi page note was a refill of furosemide. I had signed off on the note when it came in.

I admit, i missed this information.

Office notes are bulky, filled with fluff and pseudo quality measures. Primary care doctors have no time set aside to review anything in their inboxes – we are expected to do that in our “spare” time or during time stolen from our scheduled patients.

A shared medication list, across EMR platforms, similar to the PBM plug-in, could avoid snafus like this one. So could scheduling time for actually reading incoming reports. Something should be done.