Monday, December 08, 2008

Programmed Prescriptions

Today a computer told me that I couldn't use Prozac. More specifically, it said that the use of Prozac was contraindicated in people diagnosed with bipolar disorder. This experience led me to conclude that the only thing worse than having an insurance company tell you how to treat your patient is having a computer tell you how to treat him.

I'm required to use an electronic medical record. I don't generally mind this. The constant typing and the amount of time required for data entry is a pain in the rear, but I know it's the best way to ensure continuity of care between prisons. The problem is that the system also has preprogrammed treatment algorithms. I have no idea where they came from, who decided them and what data they're based on, but they exist. Episodically the computer tries to tell me how to practice.

The computer algorithm has also told me not to use lithium with people who are also on certain blood pressure medications and serotonergic reuptake inhibitors with people who have hepatitis. The computer doesn't say "be careful about this combination because it can cause X, Y or Z problems" or "be sure to watch drug levels more closely with this combination". It says, "Use of this drug is contraindicated in these conditions". Then, in order to continue entering the prescription, you have to click an "acknowledge" button to document that You Have Been Warned.

Truly, this is annoying on so many levels.

It's a CYA maneuver so the nameless Company can say it warned you if anything goes wrong. It's unnecessarily alarmist. It confuses the medication nurses who occasionally check to make sure the meds are OK to dispense. But more importantly, it's just bad information. These medication combinations are still effective, and they can be used safely, you just have to monitor them more closely. The geek who designed the system doesn't know this, he or she just programmed in the information he was told to put in. It probably seemed like a good idea.

And it will be someday, once computers are granted prescribing privileges.


And now I want an opinion from our readers. It's got nothing to do with psychiatry.

If you make hot cocoa from cocoa powder and other ingredients, instead of using hot water and a bag of cocoa mix, is that considered 'homemade'? Dinah says it's all one and the same. I say it's making cocoa 'from scratch' just like baking a cake without using a boxed mix.

What is your definition of 'from scratch'? And what's your favorite hot chocolate recipe? I'm looking for suggestions.


Anonymous said...

Funny you mentioned this. I prescribed Prozac for someone with bipolar disorder today. I wrote a "cya" note saying I warned the patient of the risk of manic induction.

I wish the world was totally predictable.

"homemade" and "from scratch" imply extra steps and effort.
Seems cocoa exists in only a few realms:
hot water + packet and mix.
Hot milk + cocoa (if unsweetened cocoa, + sugar) and mix.
The cocoa powder adds some authenticity, takes away some chemicals and processing I assume, and milk, especially nonfat, is more nutritious in that there is calcium and protein and vitamin D involved, but I'm not sure there is anymore effort to justify the terms "homemade" or "from scratch."
Whatever, if it makes you happy.
If you do it for me, whip some cream and add kahlua and I'll be your friend.

Hoping the frog juice story makes it to a post, but please no graphics for that one.

Anonymous said...

by 'mix,' I meant Stir. Since we're splitting hairs on semantics

Anonymous said...

I agree with you that it is making hot cocoa "from scratch" when you start with cocoa powder and sugar.

I am particularly attuned to hot cocoa "from scratch" because I am lactose intolerant and so many mixes which result in hot cocoa have included dried milk which gives me "the runs".

My favorite is a coffee-cocoa mix. I start with a strong brewed decaf coffee, then stir in as much cocoa as I can, add sugar, then add Rice Dream with vanilla "milk" and reheat in the microwave as necessary and stir some more to bring up to temperature.

In the 50's my mother used to warm milk in a double boiler on the stove top (to keep the mixture at 212 degrees F, a low enough temperature to not scald the milk). She then measured in the cocoas ans sugar but I have not idea the measurements but I suspect it was from the 1950 Betty Crocker Picture Cook

book which lists the recipe as:

Hot Cocoa
For each cuo cocoa, mix together 1 tsp. sugar, 2 tsp. cocoa, and 1/4 cup cold water. Cook over LOW heat (boil about 4 minutes). Add 1 cup milk. Heat until scalded, but do NOT boil. Add a pinch of salt ( a drop of vanilla too if desired). Just before serving, stir until smooth. Serve hot. Pour over a marshmallow in each cup.

From same book:
Martha Washington's Colonial Chocolate
(George Washington's favorite. From a radio friend who wrote, "It came from my cousin whose husband is a direct descendant of Martha Washington.")

Mix to a smooth paste in saucepan:
4 tbsp. cocoa
a little cold water
Stir in...
2 cups water
1/3 cup sugar
2 cups milk
Bring to a boil and blend in...
2 tbsp. cornstarch dissolved in a little cold milk
Boil 3 min. longer. Remove from heat and set in warm place.
Beat until light and foamy...
1 egg with 1/2 cup hot water
Pour half of egg mixture into a pitcher.
Blend in 1/2 tsp. vanilla.
Add hot chocolate slowly. Pour remaining egg mixture ove top. Serve at once.

Anonymous said...


You said:

"But more importantly, it's just bad information. These medication combinations are still effective, and they can be used safely, you just have to monitor them more closely."

I didn't react too well with your phrase "bad information". Since when is a warning about a drug interaction, "bad information"? In my opinion, there aren't enough of these warnings and many doctors are uninformed or are annoyed like you seemed to be.

Also, the problem is that many psych patients aren't monitored closely. And if you complain about a symptom that may be due to a drug interaction, it is blown off as due to the illness. Sigh.

Sorry, I don't mean to be negative but as good as you shrink rappers are, I think you seriously underestimate what goes on in alot of psychiatric offices with patients.


ClinkShrink said...

Anon: The frog juice story is too disgusting for the blog, I'm afraid. The moral of the tale is to avoid any water dripping from a ceiling, particularly in a public institution.

TP: The cocoa I made was from the Betty Crocker recipe. Martha's sounds better (Washington, not Stewart).

AA: I probably didn't describe the nuance well enough in my post because I wrote it quickly. The 'bad information' reference was to the fact that the computer was telling me not to use that particular medication. I agree that warnings about drug interactions can be important for patient safety. My point was that if I obeyed the computer blindly, my patient wouldn't receive the treatment he needed and wanted. (Actually, if I obeyed all the contraindications my computer gives me then many of my patients wouldn't get any meds at all.)

The computer is telling me the obvious, like if your oven were to flash a sign "Warning: Oven Is Hot" every time you turn it on.

Jackie said...

That is definitely home made if you use unsweetened cocoa! Just because something is easy to make, doesn't mean it can't be home made!

Anonymous said...

Home made = something prepared whereby you compiled ingredients and followed a procedure for the assemblance or outcome of a finished product that is more than the sum of it's parts. Hot water and mix = home made - as the parts mix to water are as determined by the 'cook'.

From Scratch = hand picking cocoa beans from a tree you planted, tendered and watered....

Contraindication warnings = very redundant. Even as a nurse I check every new drug and contraindications before administering. The more we rely on computers - the more complacent we become.
Of course - the program's next move is to not allow GPs to prescribe certain 'specialist' medications - until they've clicked on "yes, I've checked with the shrink/nephrologist/obstetrician"

Anonymous said...

Okay, I agree, anything with a double boiler is "from scratch" and anything which entails 9 ingredients made into into a "smooth paste" and timed boiling and egg beating, is "from scratch."

Clink recently learned how to turn on her oven broiler (yes, it's hot) and we won't discuss what happens when she makes microwave popcorn.
I'd pay to watch her make the Martha Washington version of hot cocoa that TP put up. I wouldn't necessarily drink it, but I'd pay.

She did make a killer pie recently.

FooFoo5 said...

I'm thinking CYP (as in P450) and grapefruit juice. My mother suddenly got a sticker on a prescription bottle warning about the combination, and immediately swore the juice off. I said, "Do you realize how much, per day, you'd have to drink?" IT'S ON THE BOTTLE! It has since disappeared from the bottle, but the juice has not reappeared.

Mexican cocoa comes in a 2 inch diameter circle of chocolate, divided into 4 pieces. You boil a piece (or 2!) in "leche." But this cocoa chocolate is unique, made with a mix of spices - definitely cinnamon & what tastes like cardamom - that is quite awesome. I'll not be returning to Nestle...

(Today's "word verification" was Trazodole. Good with cocoa?)

Anonymous said...


"jen said...
Need a question answered: What kind of a shrink tells a mom she should leave her husband and kids [almost 2 and 3 yrs old] to find her own happiness. Mind you she had 2 babies in one yr both C-sections and difficult. Caught her H totally off guard as well as all her friends and family.
Shrink is telling her the kids will be OK. They are not. She has been on antidepressants since 2nd kid was born and is doing all sorts of nasty things she never did before. Crazy stuff. Drinking heavily....check out this blog ... /
She has most of the warning signs. We think this shrink, along with the drugs, has totally screwed up her thinking.


September 14, 2008"

Anonymous said...

Kia ora all

I'm not going to comment on the "home made" stuff! - an interesting discussion nevertheless.

With my work hat firmly attached to my head (I'm a Forensic Mental Health Pharmacist, admittedly not in the US) I have to agree that automated prescription interaction/warning/etc flags can be a complete pain. A lot of clinicians out there (but not all), and the folks we're expecting to actually take meds (but not all), don't have the time/knowledge/etc to be in a position to interpret what's being said. As for the post about someone who read the prescription label then swore off grapefruit juice - well I think the pharmacist that dispensed the medication should have done a better job of putting that into context for the client (and yes, it's a CYP450 thing). (And the opportunity for a discussion about such warnings is why I have a bit of an issue sometimes with internet dispensing.) A computer programme, by it's very nature, cannot take into consideration either all the relevant factors to do with the person that the medication is being prescribed for or the nuances of all the combinations of factors that are taken into account when clinicians are making the decision to (and what to) prescribe - that's where the "art of psychiatry" meets the "science of evidence base" as far as I'm concerned. I agree that it's not "bad" information that's been given, and it's stuff that needs to be out there being taken into consideration - but I'm not sure it's necessarily helpful in the format it's presented.

Without wanting to sound like I'm justifying my existence I have to admit my feeling is this is where can Mental Health Pharmacists come in - as well as all the other stuff we do, we're good translators between what the manufacturers have to say to keep litigation away and what's helpful for the clinician and client in their decision-making processes.

In mental health we all remember there's a real human being at the receiving end of what we do - for me computers will never be able to replace the vital human element of a clinician working with a client with respect to their medication - taking into account the relevant warning information but at the same time putting it into individual client context.

Right, I'll get down off my soap box now! Hope this post was of interest - I don't usually post comments however this time I just had to put finger to keyboard!

Anonymous said...

First off, I agree about the homemade/from scratch.

On the program, I can comment from the programmer side.

It's true the large majority of programmers won't look into the accuracy of the information we're told to program. This is mostly because if we even *try* we are often contradicted by either the customer or our higher ups.

So basically, we're given a huge set of requirements and told to be good little minions and make it do exactly what is says.

Is it a CYA? Probably, whatever company knows they might have an interaction probably paid lots o'money to dump all their CYA stuff into the program requirements.

But, I don't think computers will have prescribing privileges. Mostly because any system can be hacked, and if you wrote it, you know the rules and can probably get around them (or maybe even put in an illegal "back door").

My capstone course had tons of papers we had to read on programming mistakes and the pain the caused (Therac 25 anyone?). So I guess my point is, computers most likely won't be taking over (at least anytime soon), there's still no way to program intuition.... and probably because the blame will shift from the drug companies/people who prescribe the meds to the company that wrote the drug dispensing program.....and those companies will want CYA also.

Fat Doctor said...

We have an EMR that occasionally warns of risks of combining meds.

It's particularly difficult for me, as a hospitalist, because sometimes I can see that a couple of the patient's home meds, presumedly prescribed by his PCP whom he trusts, could have terrible consequences. So what do I do?

Sometimes I just talk with the patient and find out how long he has been on that combo. I then tell him that he may want to discuss this computer generated warning with his PCP, then I write a CYA note. A couple of times, I thought the combo was so dangerous that I stopped it during the hospitalization.

I'm not playing the "homemade or not" game, but I prefer hot cocoa with kahlua and/or mexican vanilla. Sometimes peppermint is nice, too, but not with kahlua and/or mexican vanilla.

Owner said...

I was going over a list of healthcare blogs a few minutes ago, and at one point my attention focused on this one title, "The Shrink Rap" with a tiny little Canadian flag next to it. Instantly I thought, "They're Canadian???"... and then I realized it was a different site. I never thought there could be another Shrink Rap!

jcat said...

oh please tell us the frog juice story!

you can always put a CYA note at the top warning that it may trigger puking....

a psychiatrist who learned from veterans said...

Check the box psychiatry. Terrible.
You need Indian tech support:

Support: 'Your name is ClinkShrink, C as in Charlie... R as in Romeo. May I call you Clink? You are having the program.. I am sorry you are having this problem. I will have that line deleted from the program. May I assist you in any other way? Thank you and have a good day.'

Anonymous said...

Easiest home-made, from scratch hot chocolate uses Ghirardelli ground chocolate-- add to hot milk to taste. Stuff from a package is not "from scratch". Ever see one of those "Cake Mix Doctor" cookbooks? By the time you've gone that far adding stuff to a box mix to make it taste really good, you could have made it from scratch in less time.

WRT computer programs and Rxs: The people who insist that certain information goes into software are not the same people who write or use that software. We are undergoing a global financial crisis because the rocket scientists on Wall Street insisted their high-powered math was not subject to scrutiny by the lowly programmers writing the software to implement same.

The reasoning and well-informed judgment of knowledgeable people cannot be substituted by a computer program. People can screw things up; computers just speed up the process thereof.

Anonymous said...

I like melting real chocolate with half and half or cream. If it is very cold outside, a shot of Jack Daniels makes the drink extra toasty.
Great blog, by the way. I'm doing research for some fiction. I needed to pick a shrink's brain and, well, the only one I know charges $300/hr...