Dr. Andrew Wiesenthal: Teamwork Saves Babies
September 30, 1999
Dr. Andrew Wiesenthal: Teamwork Saves Babies
Dr. Wiesenthal specializes in pediatric infectious disease. As Associate Medical Director of the Colorado Permanente Medical Group, he is in a position to put the latest research into practice. His team did just that with HIV transmission research, to achieve a zero transmission rate from mother to baby for their membership. (Untreated, the transmission rates are 25-33%).
His commitment to public health includes work in Latin America and West Africa for the Center for Disease Control, the World Health Organization, and the Agency for International Development. He earned a B.A. from Yale in Latin American Studies and an M.D. from the State University of New York. He currently volunteers at local pediatric clinics including Samaritan House.
Body1: How did your group become interested in this problem?
Dr. Wiesenthal: There was a study that got a lot of publicity. Published data from an AIDS clinical trial group described the reduction of HIV transmission from an infected mother to baby. When we saw this study, we met to discuss whether or not screening all pregnant women and treating those who were positive and their babies would be appropriate in our setting. We said yes!
Body1: What are the measures your group uses to achieve such good results?
Dr. Wiesenthal: First of all, we make it easy for women to get pre-natal care. We have 45-50 obstetricians who only see patients from our health plan.
We have a good screening program. The obstetricians built HIV testing into the routine screening serology done as part of all pre-natal care. They also built a system to manage the rare women who present at delivery with no pre-natal care. So we screen for HIV, treat the mothers, and then treat the babies.
The treatment protocols are from the Center for Disease Control. They recommend that the mothers be given multi-drug therapy and the babies be given AZT. Institutions using this protocol nationwide have gotten the transmission rate down from around 28% to 4-5%. Since Colorado is a relatively low prevalence area for IV drug abuse, the likelihood of maternal HIV infection is lower than elsewhere. We see a total of about 5,000 babies born a year, so the fact that we have had no failures of the strategy thus far is not surprising. Statistically, there's no guarantee that we will stay at 0% transmission in the future. The important thing is proper implementation of the protocol.
The key to our success is effective communication. The tests are sent to our lab, and when we get the results, we incorporate them into the patient’s electronic medical record. That way they are treated during gestation, the information is available during the delivery, and the infant gets appropriate neonatal care.
Another difference in our implementation is that all our doctors are part of one group: the mother’s doctor, the obstetrician, the neonatalogist, and the pediatrician are all in one practice. Almost all of the deliveries are made at one hospital. So when our group decides to implement a management strategy, it is easier to put it into practice across the board.
Body1: In general, how important is communication among doctors to a patient's well-being and recovery?
Dr. Wiesenthal: Communication is critical when a patient has a problem that calls for multiple physicians to be involved. Each practitioner may be acting correctly in his or her specific context, but if they don't clearly understand what the others are thinking or if the hand-offs between practitioners are ineffective, care will be compromised. For example: in an environment that is non-integrated (ours is integrated), every practitioner maintains his or her own medical record. Lets say a person has hypertension and has been on medication. The patient goes to see the primary care doctor, who decides that the patient's blood pressure is not well-controlled and changes the medication. Then the patient sees a cardiologist, who decides the same thing and adds yet another medication because he does not ask either the patient or the primary care doctor what other changes might have been made recently, he only knows what is in the chart. The patient fills the second prescription at a different pharmacy from the first (because the pharmacies were in their doctors' respective office buildings), so the pharmacist has no opportunity to check for drug-drug interactions. The patient believes that both doctors know what they are doing (strictly speaking, they do), takes both medicines, develops an irreversible cardiac arrhythmia, and dies. If you think this kind of thing doesn't happen every day, take a look at an article entitled "Error in Medicine" in the Journal of the American Medical Association, December 21, 1994.
Body1: How can a patient make sure there’s enough communication between the members of their medical team?
Dr. Wiesenthal: What can a patient do to avoid these problems? They must recognize that they are inevitably in a complex system and act accordingly. First, they must assure that their primary care doctor truly takes a "captain of the ship" role--that doctor may not do all of the things that other involved practitioners do, but they must absolutely be fully aware of all of those activities and be certain they are coordinated. They must forcefully and regularly communicate with all other involved practitioners. Second, the patient can ask each involved practitioner probing questions to be sure that they have communicated with each other. For example, "Dr. so-and-so did such-and-such or told me the following. Were you aware of that? Do you agree? Will you talk to them?" The other thing they can do is join an integrated system like ours, where the system works to support coordination of care and centralized data.
Body1: Is electronic record-keeping of value to the patient?
Dr. Wiesenthal: In the past, we built our record-keeping system on paper. We had some problems with coordinating care, but they were minimized by the fact that every patient had a similar medical record that followed them, regardless of whom they were seeing or where they were being seen. Having a system that required the physical movement of medical records, sometimes over long distances and within short time frames, created its own problems.
Now we have workstations that are just there, uniformly available 24 hours a day 7 days a week. We don’t have to depend on office hours, or couriers whose vans could break down or get stuck in traffic, or any other, similar factors. We’ve learned that our records are accessed 800,000 times a month! It’s amazing that we believed we could ever do that with a paper system.
Electronic record-keeping makes it easier for care-givers to use disease management systems, like the one we have implemented for our diabetics, for example. We can identify patterns, implement guidelines, monitor to see if they are working, or if they are being followed, and see if they are achieving improved patient outcomes. We’ve had the electronic record system in place for a year now, so we’re just starting to see large amounts of data. In another year or so we should begin to learn a lot from this information.
Last updated: 30-Sep-99