Julie Wu – 34 years old

Personal Narrative 1

A local artist, Julie Wu, 34, is transported the emergency department following an automobile accident.  She has lapses of consciousness and a low blood pressure.  Her most pressing problem is a severe open fracture of her right femur.  Julie is allergic to penicillin and she is unable to inform her caregivers of her allergy.  Dr. Liz Lang immediately accesses Julie’s CareEntrust Health Record (CHR).  Noting the penicillin allergy, Dr. Lang calls the trauma team and alerts them to the need to alter the orthopedic surgeon’s pre-operative orders. The surgeon prescribes vancomycin I.V. as prophylaxis to infection prior to surgical intervention instead of penicillin.

The Outcome:  Julie is spared a potentially catastrophic outcome because of access to clinically relevant information via the CHR.

Amy Hamilton – 26 years old

Personal Narrative 2

Amy Hamilton, and her husband Eric are eagerly anticipating the birth of their first child.  Since the age of 14, Amy has had a heart rhythm, described by her primary care provider as a pronounced sinus arrhythmia with occasional premature atrial contractions.  Her regular obstetrician is familiar with Amy’s heart rhythm pattern, but Dr. Jackson, the on-call OB/GYN delivering the Hamilton’s’ child has not previously met Amy.  At first glance, Dr. Jackson decides Amy must stay in the hospital and he considers ordering a cardiology consult.  Amy says she had a cardiac event monitor that was satisfactory.  Dr. Jackson reviews Amy’s past diagnosis and procedures in the CareEntrust Health Record and verifies that the rhythm he sees on the telemetry monitor is not new and fits the pattern described in the prior claims.

George Penna – 42 years old

Personal Narrative 3

George Penna, 42, has high cholesterol, high blood pressure and other risk factors for the development of coronary artery disease.  As a former high school athlete, he believes he can manage his condition by cutting back on fast food and soda, increasing his weightlifting at the gym and avoiding stress at work.  George avoids prescribed medications.  He believes taking over-the-counter herbal remedies, protein shakes, high doses of vitamins and apple cider vinegar are more natural ways to ward off future problems.  George reluctantly shows up to Dr. Smith’s office for a Department of Transportation physical exam.  He needs to pass the physical test to keep his license to drive large over-the- road vehicles for his employer.  Despite his prior recommendations, Dr. Smith was surprised to find his lipid values worse and his blood pressure even higher than the last reading. 

Dr. Willis has new prescriptions written out for increased doses of the Lipitor and Prinivil.  She notices that George is a bit evasive when she questions him closely on which pharmacy he uses and his health habits related to his cardiac risk profile.  Dr. Willis double checks George’s CareEntrust Health Record to validate her uneasy feeling.

Information in the CHR gives an accurate account of the prescriptions George has filed:

• Penicillin VK 500 mg orally four times a day for 10 days for to be taken after gingivectomy
• Prinivil (lisinopril) 10 mg one tablet daily
• Lipitor (atorvastatin calcium) 10 mg one tablet at bedtime
• Bactrim DS 800-160mg tablets 1 tablet every 12 hours for 14 days

The outcome:  It comes to light that George is using home remedies instead of medically supervised prescriptions.  Dr. Smith has an open discussion with George on evidence-based medical advice.  He has a frank and honest discussion with George about truthful reporting to him.  He establishes a follow up visit with George in the near future for closer surveillance of his cardiovascular risks.  Together, they set appropriate health goals.

Reggie Washington – 7 years old

Personal Narrative 4

Sandra Washington, 35, is the mother of an active seven-year-old son, Reggie. One afternoon, while horsing around with his buddies on a muddy baseball diamond, Reggie slips and falls, puncturing his hand on a rusty chain-link fence. He summons Sandra and she takes him to the urgent care clinic. At the clinic, Sandra can’t recall whether Reggie received his final dose of the DTaP (diphtheria, tetanus and pertussis) vaccine. She doesn’t have her son’s immunization record with her, and she can’t remember when Reggie received his last round of shots.  Sandra is getting confused with his younger brother, Troy’s history.  Dr. Sharla Briggs accesses Reggie’s CareEntrust Health Record (CHR).  She confirms that the boy does in fact need a DTaP vaccine.  Dr. Briggs also notices Reggie is overdue for his other 6 year vaccinations and EPSDT screening as well.  Dr. Briggs recommends that Reggie receive all his booster shots and bring the record up to date while Reggie is in the clinic.

The outcome: Dr. Briggs use of the CHR promotes safety and efficiency, guarding against the health effects and costs of an unnecessary immunization.  Reggie receives vaccinations and his EPSDT screening that are overdue. It helped Sandra accomplish in one visit what would otherwise have taken two.