While most American hospitals and health systems have yet to take the plunge into electronic medication administration (eMAR), Nashville, TN-based HCA (Hospital Corporation of America) soon will complete the implementation of eMAR across its entire network of 190 U.S. hospitals. According to HCA, eMAR is in place in less than 10% of U.S. hospitals; of these, about half are HCA facilities and about another third are VA facilities.

Already, HCA’s system has demonstrated its value. In 2004, even before all hospitals were on-line, there were 51 million doses scanned, 1 million errors identified, and 20,000 serious medical incidents averted. The 2005 numbers, which will be released soon, are anticipated to be even more significant. And beyond the identification of errors and averted incidents, HCA already is using the data to identify process problems and as a foundation for PI projects aimed at bringing those numbers down.

HCA’s eMAR system got its impetus in 2000, when 126 employees and physicians representing each division of HCA came together in an intensive two-day meeting to review evidence describing the scope of medication errors and the effectiveness of potential solutions. From the meeting surfaced the ideas behind two new technologies for improving medication practices: eMAR and ePOM (electronic provider order management).

Since such systems were in use by so few hospitals at the time, what led HCA to believe they made sense? “Basically, the main thing that influenced us was the research that was out there–plus common sense,” recalls Jane Englebright, RN, PhD, vice president of quality and patient safety. “Bar-coding technology itself has been around for awhile, and as we got going, the results pushed us to go even faster.”

Here’s how eMAR works:

* Each patient admitted to an HCA facility receives an armband with a bar code. The bar code corresponds to the patient’s current medical record, including drug history, allergies, and lab results. Bar-code identifiers also appear on shrink-wrapped doses of medication.

* Before a medication is administered, bar codes on the patient armband and the medication are scanned, allowing the nurse of therapist to verify the right patient is receiving the right drug in the right dose at the right time.

* The software checks each medication against the patient’s drug history and lab results. If conflicts of potential drug interactions are identified, warnings alert the nurse to double-check, verify, and/or call the doctor before administering the medication.

The hardware was a bigger challenge than the system, for staff and management, Englebright says. That’s because HCA was using MEDITECH as the vendor for its clinical information system, so there wasn’t a steep learning curve on the technology. “It was harder moving from a hardwired system to wireless and to a mobile workstation. For example, some of our hospitals had gone to carpeting in the halls to control noise, but that makes it harder to roll the carts.”

In finding the right equipment, HCA went through a couple of different generations and still is looking for the ideal hardware. “It’s not a one-size-fits-all situation. Different patient environments need different hardware,” she adds. At present, HCA is using Dell for its equipment.

Equipment was not the only adjustment that had to be made, Englebright says. “Some processes had to be changed. For example, it was common practice to have one multidose vial for all nurses on the floor. When you have all you need right at the bedside, however, multiple vials make more sense.”

As Englebright points out, eMAR does not address the ordering or distribution phases of medication but focuses on the administration phase. Nevertheless, the system provides a wealth of information. “We can tell how many of the errors were the result of missed doses, wrong patient/wrong med, and so on. We were surprised at how many errors were wrong-med errors.”

The most common error, she notes, was the administration of a sustained-release formulation when it should have been an immediate-action formulation. “It was, however, a little comforting the patients were not getting the wrong meds.”

In terms of serious medical incidents averted, of course, the only things that can be measured are errors that didn’t happen. “If it was the wrong med for the wrong patient, we assumed it to be serious, even though it could have been a vitamin that was given,” Englebright says.

The “warnings” referred to earlier are a key component of the system. When the nurse is at the patient’s bedside, he of she pulls up on the computer screen a medical profile that has a list of all the meds the doctor has ordered. The nurse then scans the dose. “If it is incorrect, they get a visual and an auditory warning–a little beep–she says. “Then they check the patient’s armband, and if it’s not a match, they also get a warning.” At any point along the way, the nurse can abort the process, “and that’s what we count as an averted error,” Englebright adds.

Change is the only constant. The ways shops transform a rough casting or material stock into a precision machined component–and make money at it–are different than in years past. Granted, the act of removing bits of material using some type of cutting tool is essentially the same. However, other aspects of the overall process of supplying machined parts are clearly different.

They have to be different. Consider how the needs of product manufacturers–medical manufacturers in particular–have evolved during recent years. Makers of both surgical instruments and implant devices now have need-it-yesterday delivery requirements. Prototypes must be machined in the specified material with all secondary operations completed. Component appearance is considered just as important as the accuracy of part features. Ten pieces is a large batch size.

The shops that have had, and will continue to have, success serving the medical industry are those that have not only taken note of such changes, but also have been keen enough to tweak their own processes to best meet new customer demands. One such shop is Metal Craft Machine & Engineering, located just outside Minneapolis in Elk River, Minnesota.

Things have changed since Jack Mowry opened the shop in 1978. The company has expanded five times and has added a second facility in Chippewa Falls, Wisconsin. Now approximately 95 percent of its work ships to medical manufacturers, whereas before, a large chunk of its business was geared toward the semiconductor industry. Its approach to prototypes and its method for producing such one-off parts are different. A number of secondary operations that were once outsourced or not even considered years ago have been brought in-house.

There are other changes over which the shop had no control. New materials specified for medical parts are proving more difficult to machine, and skilled labor is a scarce resource.

To succeed in serving the medical industry, shops such as Metal Craft have no choice in the matte–either adapt or say adios. However, while Metal Craft is, in effect, a “medical” shop, all machine shops should take note of how it has adapted to the changing needs of its customers. After all, the medical industry isn’t the only manufacturing segment that refuses to stand pat.

Prototyping On Production Machines

Metal Craft does have machine tools primarily dedicated to prototype work. Years ago, most all prototyping was performed on those machines. Today, the shop makes every effort to run prototype jobs through its CNC production machines, which include Swiss-type lathes, conventional lathes, vertical and horizontal machining centers (some with four- and five-axis capability), seven-axis grinding machines and wire EDM. There are a few reasons for this.

Today’s medical manufacturers want prototype parts machined in the specified material with all secondary operations completed. This rules out rapid prototyping methods using alternate or more easily machined materials. Also, the complexity of the latest part designs often precludes anything but multi-axis CNC machines to achieve the desired quality levels. Gone are the days of cobbling together a prototype that may or may not be spot on.

Running prototypes through its production machines offers Metal Craft the chance to work through issues that will only reveal themselves in production runs. This also levels the production learning curve because all aspects of the production machining process–tooling, workholding, cutting data, programming–are in the can.

Having a complete CAD/CAM program is especially helpful in getting prototypes into production quickly. Even if changes to the part design are required (to accommodate the desires of an individual surgeon, for example), a basic program framework exists that can be easily altered. Also, the need for any special tooling will have been identified during the prototyping process and the shop will then have that tooling in-house.

The fact that customers know a shop has a process ready to roll whenever they pull the trigger on a production run gives that shop an edge if and when production work comes to fruition. “If” is the key word, as there is no guarantee that production work will follow. Metal Craft works closely with its customers to determine if a prototype will be a one-time deal or if it will likely lead to a production order. The shop charges its customers accordingly.

Effectively mixing prototype and production jobs can be a scheduling headache. The ERP software that company uses, M1 from Bowen & Groves (Chandler, Arizona), helps ease some of the pain. Purchased 3 years ago, it offers real-time data collection so that a scheduler can view the status of jobs currently running in addition to the promised delivery dates of those in queue. This is helpful in terms of determining the best possible time to insert a prototype job into the production schedule.

Another benefit is the system’s flexibility. It is used for everything from data collection on the floor and quality control to payroll and accounting. Users can tailor it to their own needs, and employees can customize its look to show the information most appropriate for their job duties.

NANCY Aossey has had little time to sleep. With devastation in South Asia still front-page news last week, a flurry of phone calls was swamping the offices of international Medical Corps, the aid organization that Aossey has headed since 1986.

The Santa Monica-based group was already working in the Indonesian province of Sumatra when a massive earthquake triggered the tsunami on Dec. 26, so it was able to put a team on the ground quickly in some of the hardest hit areas.

Aossey has been directing the group’s response from her offices, focusing in on the urgent need for clean drinking water and sanitation.

Although the scope of the disaster is staggering, it’s familiar territory for the Iowa native, who has spent years traveling to some of the most dangerous and impoverished countries around the globe.

In fact, the International Medical Corps, founded in 1984 by a Los Angeles emergency room doctor, has sent workers to more than 40 countries. Its niche: providing health care services in high-risk countries, including Afghanistan, Iraq and Somalia. Aside from providing direct health services, the group specializes in long-term training to build up local health care systems.

Question: So who are all these people calling in?

Answer: When there is an emergency and it hits the newspapers there is an outpouring of support. People call and they want to help. Often they want to make a donation. Sometimes they want to volunteer here in our offices and a lot of times they want to go overseas and volunteer. We talk to a lot of people during emergencies like this to see how we might use their assistance.

Q: Can you actually find a use for people off the street?

A: Some of the hardest people to find are people with good logistics experience, communications experience, administrative skills, finance skills, management skills. Those are tough skills to find, especially to ask people to work in a war zone or in a natural disaster. We do get a lot of health professionals who are interested and we put them through a process where we evaluate whether or not they are needed, how they might fit in the local culture and how much time can they spend in a particular country.

Q: Do these people have jobs?

A: Some are retired doctors. Some people are in the prime of their careers. We have a trauma surgeon in Kansas who will shut down his very lucrative (plastic surgery) practice. He will go overseas for a month or two and volunteer his time.

Q: Whom do you have in Indonesia right now?

A: We have 130 people on the ground. Many of them are local Indonesian health care professionals, people we have worked with for many, many years. We are communicating with them and sending them supplies. Indonesia is very large. We were working on several islands. We had a presence in Sumatra, but we were not in Banda Aceh.

Q: Are things as bad as the pictures make it seem?

A: Yes and probably worse. We are getting daily reports from our teams and they are witnessing major devastation–entire villages gone, people in a state of shock. IMC will focus on what we think we can make the greatest impact.

Q: And what might that mean?

A: We will be focusing on securing the water supply, hygiene and sanitation. The water is contaminated. There is a need for water purification tablets. People do not have the right medicines. There are a number of injuries where the right antibiotics are not available. We are going to have to transport them in. We are looking at putting together mobile clinics, vehicles typically. IMC has experience with that. We are looking at trying to help put together health posts. We also will assist rescuers, providing body bags.

Q: Will this be your biggest disaster response ever?

A: I make it a point of never comparing suffering, but yes. We have been involved in a lot of significant disaster: genocide, ethnic cleansing. We have been there and seen it all. This one is unique in that it’s huge and sudden. Sometimes man-made disasters (such as civil wars) occur over a period of weeks or months. A number of workers lost family members and friends and are pitching in. Can you imagine how hard that would be?

Q: Are you seeing record donations like other groups?

A: So far we have raised about $1.2 million in private donations. It’s a record for this period of time. We’ve got it online, phone calls, checks. We have had people walk up to our office and drop a check on, our desk. We have set our goal at $5 million.

Q: How can you make sure you are not duplicating efforts of other agencies?

A: We know everything that is being done on the ground. If we are in an area that is well covered we will set up in an area not well covered. A lot of the coordination is done in the field.

Q: Will you be going there yourself?

A: If I need to be there because I can help IMC I will go. I am very sensitive to the fact that when I travel somewhere I am taking up resources and people’s time.

Q: What have you done in some other situations?

A: In Mogadishu, Somalia in the early ’90s we were the first American-based organization to work there. It was complete anarchy: bombings, shootings, guns on the street. We saw people shooting at the heads of children as target practice. For a local infrastructure, we had doctors and nurses who stayed behind to help their people, but who had no experience with trauma. We took doctors who didn’t have a lot of trauma training and we gave them new surgical techniques.

EnterpriseIQ ERP Software uses DHR module to link device history records to ERP capabilities, resulting in real-time electronic platform that provides visibility and control over manufacturing process. Using web-based workflow tools and email, module transparently connects business systems and real-time data to promote open communication and eliminate redundant activity. Medical device manufacturers benefit from immediate data analysis, structured reporting, and FDA compliance.

PASO ROBLES, Calif., May 16 / — IQMS, a leader in the design and development of Enterprise Resource Planning (ERP) software, today announced the availability of the Device History Record (DHR) module for its EnterpriseIQ ERP software. The new module links device history records to the rich set of ERP capabilities found in EnterpriseIQ, resulting in a real-time, electronic platform that provides total visibility and control over the manufacturing process. With EnterpriseIQ and the DHR module in place, medical device manufacturers can cost-effectively eliminate time-consuming, paper-based tracking systems, streamline product development and better ensure quality standards compliance.

“Medical device manufacturers operate in one of the world’s most competitive and highly regulated industries where time-to-market delays and a lack of traceability can mean the difference between failure and success,” said Randy Flamm, president and founder of IQMS. “In this environment, paper-based DHR systems are quickly becoming obsolete. EnterpriseIQ with its DHR module automates process tracking and approvals to deliver complete traceability, improved quality compliance, higher yields and faster time to market. It’s a true competitive advantage over paper-based systems.”

Using Web-based workflow tools and email, the IQMS DHR module transparently connects business systems and real-time data to promote open communication and eliminate redundant activity. In-process control and enforcement are easily managed throughout the product lifecycle. For example, each person in a work group is simultaneously notified of change orders via email. Once notified, team members can simply click on the provided link and approve changes with an electronic signature. This eliminates the inefficient process of paper-based approvals passed from one person to the next, and it also saves on document storage space. The system’s user-friendly interface also helps operators to follow proper procedures with easy-to-access work instructions, including drawings, process routings, and bills of materials. Product introduction within the system is not confined to internal procedures and processes, so it is easy to monitor raw material supplier and outsource vendor activities as well.

An 86-year-old woman was admitted to a nursing home following surgery and hospitalization for fractures on her left femur, humerus, and wrist. The woman lived in an independent-living apartment complex when she accidentally fell, causing the multiple fractures. She arrived at the nursing home with her left lower leg wrapped in an ACE[R] bandage and wearing a removable leg immobilizer.

For the first five days of the woman’s stay, the nurses performed daily vascular checks. These checks included assessing the color of the skin, range of motion, and sensation of the exposed toes and foot on the resident’s lower left leg. No problems were discovered. On the sixth day, an interdisciplinary team that included a nurse and a physical therapist met to discuss the resident’s plan of care. The physical therapist made a comment about the orthopedic physician’s admission order and went to the resident’s chart to retrieve it. When it was brought back to the group, it was discovered that the order instructing the nurses to “remove the immobilizer cast daily to change the dressing” had not been followed.

The nurse went immediately to the resident’s bedside and removed the immobilizer and ACE bandage. She discovered three fairly large blisters on the resident’s left foot. The nurse reported the incident to the orthopedic physician, who told her to continue monitoring the foot daily and that he would assess it during the resident’s scheduled office visit one week later. In the meantime, however, the nurses became increasingly concerned about the situation and sent the resident to the hospital the next day to be assessed by the emergency room physician. That physician checked the resident’s capillary refill on the affected toes and stated “the circulation was excellent.” The resident returned to the nursing home, where the nurses continued to closely monitor her leg carefully.

The following week, the resident went to her scheduled office visit with the orthopedic physician. Upon examination, the physician decided to send the woman to the hospital immediately for placement of shunts in both legs to improve blood circulation. The surgery was performed the same day. Unfortunately, the blisters continued to spread in the woman s left lower leg, and new, necrotic wounds began to emerge. Within days, the resident underwent another surgery, this time to amputate her left lower leg. Upon discharge from the hospital, the resident moved to another nursing home.

Later that year, the first nursing home received notice of a lawsuit by the woman, claiming negligence in her care. The woman’s attorney alleged that the bandage had stopped the flow of blood to her foot, causing tissue to die and resulting in left lower-leg amputation. The attorney had a medical expert who was willing to testify’ that the “excellent” capillary refill observed by the emergency room physician was actually the return of blood that had been pooling in her foot because of the tight bandage. Because of her disability, the woman could not return to her independent lifestyle and was forced to live in a nursing-home environment for the remainder of her life.

In addition to the lawsuit, the nursing home also discovered that two of the nurses involved in the woman’s care were being investigated by the state Attorney General for possible criminal charges stemming from the incident.

The next year, the lawsuit was settled out of court for $450,000. No criminal charges were brought against the nurses, but the nursing home’s reputation within the community remained stigmatized for some time.

What Went Wrong?

The obvious error in this case study was the nurses’ failure to see the orthopedic physician’s order instructing them to “remove the immobilizer cast daily and change the dressing” until the resident had spent six days in the facility. Upon deposition, the nurse responsible for admitting the resident stated that when she received the records from the hospital, she went through the information and started to fill in the nursing home’s admitting records and transcribe the physician’s orders. She remembered seeing something referring to orthopedic orders, but did not actually see any orthopedic orders in the chart. She further indicated that she did not see anything that would have been a red flag to contact the physician. When asked how long it took her to complete the admission paperwork, the nurse stated that she filled it out, off and on, throughout the shift because she had other responsibilities to meet.

During that time, other staff members had access to the resident’s record, including the physical therapist. When the physical therapist was deposed, she stated that she went to the nurse’s station to check the resident’s physician’s orders when the resident was admitted to the nursing home. The physical therapist looked through the paperwork and wrote down the resident’s history and the orthopedic physician’s orders. She further stated that she removed the physician’s orders from the stack of papers and took them to another part of the building to make copies. She didn’t think it took her very long to do this.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of January 2003. This issue has been reviewed and is acceptable for up to 3 Prescribed credit hours. Credit may be claimed for one year from the date of this issue. When reporting CME credit hours, AAFP members should report total Prescribed credit hours earned for this activity. It is not necessary for members to label credit hours as evidence-based or Prescribed for CME reporting purposes.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 3 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

Instructions

Read each article, answer all questions on the quiz pages, and transfer your answers to the Clinical Quiz answer card (bound into your copy of AFP). This will help you avoid errors and permit you to check your answers against the correct answers.

A Mail the Clinical Quiz answer card within one year (by April 30, 2004). The bar code on the answer card contains your identification for CME credit hours.

Before beginning the test, please note: Each Clinical Quiz includes two types of questions: Type A and Type X.

Type A questions have only one correct answer and may have four or five choices. Here is a typical Type A question:

Q1. Most allergic reactions to foods are:

A. Due to IgA deficiency.

B. Due to IgG and IgM antibodies.

C. IgE-mediated.

D. Due to enzyme deficiencies.

E. Due to toxins.

Type X questions may have one or more correct answers. They are multiple true-false questions with four options. Here is a typical Type X question:

Q2. Causes of varicosities in pregnancy include:

A. Hormonal changes.

B. Venous compression.

C. Familial tendency.

D. Prolonged sitting and standing.

Clinical Quiz questions are written by the associate and assistant editors of AFP.

Type A Questions

Each question has only one correct answer.

Articles

Prevention and Treatment of Common Eye Injuries in Sports (p. 1481)

Q1. Which one of the following sports is most commonly associated with eye injuries in persons 15 to 64 years of age?

A. Baseball.

B. Basketball.

C. Racquet sports.

D. Hockey.

Q2. Which one of the following conditions is suggested by the finding of paresthesia in the infraorbital distribution of the trigeminal nerve?

A. Zygomatic fracture.

B. Orbital rim fracture.

C. Nasal bone fracture.

D. Fracture of the orbital floor.

Nocturnal Enuresis (p. 1499)

Q3. Which one of the following is the most common finding in children with monosymptomatic nocturnal enuresis?

A. Anatomically small bladder.

B. Normal bladder anatomy but decreased capacity on urodynamic testing.

C. Urethral or meatal stenosis.

D. Normal bladder function.

Osteoporosis in Men (p. 1520)

Q4. In assessing risk factors for osteoporosis in men, for which one of the following findings is there no appropriate clinical intervention?

A. The patient smokes cigarettes.

B. The patient has low estradiol levels.

C. The patient is a hypogonadal young man.

D. The patient is taking glucocorticoids.

E. The patients is taking phenytoin (Dilantin).

Q5. Which one of the following statements about osteoporosis in men is correct?

A. Electrophoresis is useful as part of routine laboratory testing.

B. Heel ultrasonography is useful for monitoring response to therapy.

C. T scores with standard deviations that are 2 to 2.5 below the reference mean are an indication for therapy.

PhatWare Corp. has released an updated version of Medical Pack, a 130,000-word English language medical dictionary intended to be used with CalliGrapher and PenOffice. The two products, used by physicians to record handwritten notes on Windows-based tablet PCs and handhelds during rounds, have built-in natural handwriting recognition software that provides word suggestions based on the physician’s handwritten notes. When combined with its standard English dictionary, Medical Pack draws on 225,000 total words to help physicians and other medical professionals spell-check medical documents in common applications like Pocket Word and Notepad. It also contains medical abbreviations, prescription drugs and medical terminology. PhatWare Corp., Mountain View, Calif.

YORK, Pa. & CHICAGO — Allscripts (Nasdaq:MDRX), the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare, today announced that WellSpan Medical Group (WMG) has chosen the TouchWorks(TM) Electronic Health Record from Allscripts to provide point-of-care clinical automation for the group’s nearly 250 providers.

The Allscripts solution will enable WMG’s physician practices to improve patient safety, cut costs and boost efficiency by automating many clinical tasks and improving connectivity between far-flung offices and clinics. Physicians, nurses and other providers using the web-based Electronic Health Record will be able to instantly retrieve patient medical records when and where they are needed - at any of the organizations 50 clinics, at the hospital, or on-call at home - without relying on expensive, error-prone paper charts.

“WellSpan physicians are focused on delivering higher patient safety and higher quality care and we know Allscripts will satisfy this desire,” said Tom McGann, MD, Executive Director of WMG and Senior Vice President of Practice Management for WellSpan Health, the group’s parent organization. “Our physicians feel that they’re drowning in paperwork. The Allscripts Electronic Health Record will transform our old paper-based processes into electronic format in an organized, easy-to-use product, and our physicians are very excited about that.”

William “Buddy” Gillespie, WMG’s Vice President and Chief Information Officer said physicians on the group’s electronic health record selection committee were impressed by Allscripts’ top KLAS ranking and by its easy-to-deploy, physician-centric technology.

“When our physicians saw the Allscripts product in practice they said ‘this can really work,’” said Gillespie. “It’s intuitive, it’s designed for the care process that they adhere to within their practices, it’s easy to use and we heard from physicians, who are already using it, that the implementation rate is very rapid, and that physicians quickly adapt to it and accept the technology. Additionally, it is web-based, simplifying the deployment across our multiple locations in Pennsylvania and Maryland.”

WMG is part of WellSpan Health, an integrated health system serving some 650,000 patients in central Pennsylvania and northern Maryland through more than 65 patient care sites, six regional pharmacies and hospitals in York and Gettysburg, Pennsylvania. In addition to its more than 50 physician practices, WMG includes the Physician Billing Service, with information technology and educational support to the practice sites.

WellSpan Medical Group will integrate TouchWorks with its existing IDX(R) Flowcast(R) revenue cycle management solution from IDX Systems Corporation. Allscripts and IDX share a strategic relationship that directly links clinical and financial information to support operational improvements at WMG.

“We are excited that WellSpan Medical Group has chosen to partner with Allscripts to enhance the delivery of high-quality, cost-effective care to its communities,” said Glen Tullman, Chief Executive Officer of Allscripts. “The question in healthcare is not whether the information exists, but rather providing access to the right information at the right time, which is at the point-of-care. TouchWorks delivers instant access to patient information, something that isn’t possible with a paper chart across multiple locations.”

About WellSpan Medical Group

WellSpan Medical Group (WMG) provides medical services through more than 30 primary and approximately 20 specialty care offices in York and Adams counties and northern Maryland. These practices and providers can offer services at both York and Gettysburg Hospitals. WMG staff strives to deliver the quality personal care that patients expect, efficiently and cost-effectively. In addition to the practices, WMG includes the Physician Billing Service, with information technology and educational support to the practice sites.

R864

2004-013530

0-7637-2759-8

The medical record as a forensic resource.

Quinn, Campion.

Jones & Bartlett, [c]2005
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277 p.

$47.95 (pa)

Quinn, a physician with expertise in both writing and reviewing medical records, explains what a medical record is, what it should contain, how to acquire, review, and report on the content, and how to extract relevant information for forensic investigations. He also addresses the nature of personal injury and malpractice cases, and the admissibility of the medical chart as evidence. Material is in detailed question-and-answer format with many examples and checklists. The book will be of use to those in the legal field and to health care professionals such as legal nurse consultants.

Dates in Medicine. A chronological record of medical progress over three millennia Ed Anton Sebastian

Parthenon Publishing, 35 [pounds sterling], pp 435 ISBN 1 85070 095

Rating: 0

Quite apart from the Millennium Dome, our daft obsession with a date containing three zeros has a lot to answer for–including these two books, which have been “inspired” by the millennium. The Medical Millennium consists of 1000 names in alphabetical order from Peter of Abano (1250-1316) to Yvunge Zotterman (1898-1982), who wrote an autobiography called Touch, Tickle and Pain. For each name, dates of birth and death are given, followed by a potted biography of 20-30 words. Having to find 1000 names has led to there being some unlikely people included, and the book would have been much better with fewer names and longer entries. However, most of the entries are sensibly written, and there seem to be few mistakes–apart from James Harvey for William Harvey in the foreword, which was presumably just a slip of the pen.

Neither of these books can possibly give any sense of historical change if read through from beginning to end. They can be judged only as works of reference. If you want a very brief guide to the great and the good in medicine, Lee’s book will do.
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Sebastian’s book (which, in spite of the subtitle, starts in 8000 BC) is another matter. It contains about 6000 entries, each of about 30 words, arranged in chronological order. You would think that the compiler of this enormous list would have entered people by the year or years in which their observation or discovery was made. Instead, most are entered simply by their date of birth. Semmelweis, for instance, is associated with 1847, the year when he introduced antisepsis by chlorine washings to prevent puerperal fever. Here, the sole entry for Semmelweis comes at his date of birth, 1818, where he is incorrectly said to have introduced asepsis when “doctors washed their hands” Lister introduced surgical antisepsis in the 1860s, but you will find nothing about him or his work unless you know that he was born in 1827. If you had made an important medical discovery in 1970 when you were 40 years old, would you have been surprised to see that this was entered in 1930? I would, and Sir David Weatherall may well be surprised to find himself included in this chronology in 1933, when he was born.

This system means that it is impossible to scan any historical period to learn what was going on in medicine. To make matters worse, the system is inconsistent. Edward Jenner is entered at 1796, the year when he first performed vaccination. Waksman, who discovered streptomycin, is entered at 1952, when he received the Nobel prize. William Harvey is entered three times–once for his date of birth and twice more for the dates of publication of his two famous treatises, leading to repetition. Alexander Fleming appears twice–once for his date of birth 1881 and again with the discovery of penicillin, which is given as 1928 in one entry and 1929 in the other.

Any reference work such as a chronology must be easy to use and as accurate as possible. This book is not only extremely difficult to use but contains many errors and anachronisms as well as trivial entries. What, for example, is one to make of an entry in 1647 recording the birth of Denis Papin, who apparently invented a steam digester to dissolve bones, or Gustav Michaelis (born 1798), who “described the diamond-shaped area over the aspect of the pelvis bounded by the dimples of the posterior iliac spines”? Most of the errors might be considered minor, but there are enough to destroy confidence. A pneumonectomy was not performed in 1951 on King George IV. Wrong king. It was the Royal College of Surgeons of London, not England, that was founded in 1800, and not, as given here, in 1799. The Royal College of Obstetricians and Gynaecologists is entered at 1937, when it received its Royal Charter, but the date when it was founded (1929) is not included. The first endowed chair in anaesthesiology in the world was not at Harvard in 1941 but at Oxford in 1936. This is only a small sample of errors, but the eccentric and inconsistent way in which this chronology was constructed means it cannot be recommended.

Ratings are on a 4 star scale, 4=excellent

Irvine Loudon medical historian, Wantage

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