EMR

Because Singapore is such a small country, it is feasible to do what they have done with their EMR.  Every public government funded hospital or clinic uses the same program, creating a National Electronic Medical Record.  At each institution, there is a local log in that lets you see information from only that institution.  But the software allows you to log out and switch to another institution to view notes, labs, and more.  Yesterday one of my patients was urgently transferred from Changi General Hospital (local community hospital) to us for work up for cancer and sepsis with pneumonia.  We didn't order a chest x-ray yet but the transfer summary noted that she had one done at Changi General before the transfer so we were able to log into their system and review that image.  That allowed us to see the extent of the infection and weigh our options much faster.

The downside is that the vendor they chose to provide the EMR is limited in functionality.  It can only really display labs, imaging, and initial or final notes (like an H&P or discharge summary for hospital visits).  Everything else still has to be hand written so progress notes or specialty consult notes are sometimes hard to track down.  I'm surprised they haven't made the switch to a fully integrated EMR like Epic or Cerner yet.  It's obviously very expensive but I think it'll help provide a more complete picture of the patient that is accessible anywhere in the hospital.  In a few years, they might get there but for now I'm still just riding the elevators all over the hospital campus.

MTM Clinic

Yesterday I had the chance to visit the MTM clinic (called MMS clinic here).  For the most part, MTM clinic is very similar to how I have observed it in the US.  The pharmacist will get a list of the patient's medications on the EMR, check for appropriate indications and dosages, note duplicate therapies and inform the patient of any recommended changes to streamline medication management.  The whole visit takes anywhere from 30 minutes to 1 hour depending on how complicated the patient is.  

The one huge difference is that because the number of MTM pharmacists is very limited here, they typically see only 5 patients a day.  Those 5 patients are selected at random by the intake pharmacist at the outpatient pharmacy based on certain criteria: age > 65, > 5 medications on the list, and a specific disease state that is the "theme of the day".  Monday is renal day, Tuesday is all disease states, Wednesday is DM and so on.  

When the patient comes down to the pharmacy after the clinic visit and brings the prescription list, the intake pharmacist flags the patient and sends the info to the MTM pharmacist whose office is conveniently in the outpatient pharmacy.  What's a little odd and interesting is that the patients here are a captive audience.  They can't really opt out of the MTM consult service before they can pick up their prescriptions if they are selected.  The MTM pharmacist told me that most, if not all patients, warm up to the MTM visits very quickly though so they are never really short of work.  Plus with the amount of time the patients have to wait to get their medications, it's probably a better option to kill their time anyway: 

40-55 minutes is the estimated wait time!

The other way for patients to get into MTM clinic is if their doctor refers them to the pharmacist because they think it would be beneficial.  This is again mandatory, but I find that most patients here listen to what their doctor says anyway.  Like it is in the US, there ends up being more patients than the MTM clinic can handle so they usually end up with about 100 patients a month, squeezing in a few more here and there when they can.

MTX Follow Up

My patient is doing better, clearing MTX slowly but surely.  It's been a few days now (96 hours to be exact) and his level still stands at around 4 so he has a long way to go.  Aggressive hydration and diuresis helped him out although his creatinine is still rising bit by bit.  Clinically he looks well, yesterday he was just lying in bed reading on his tablet!  We can't let him go until the MTX clears so now we just sit tight and hope his kidneys will make it.  Good thing we didn't have to order the antidote Voraxaze.  In addition to taking up to 48 hours to arrive, it costs $25,000 USD for a dose!  And because of the way the healthcare system works here, most of that cost would be shouldered by the patient.

New Month, New Residents

As in the US, residents here rotate on a monthly schedule so today I started working with an entirely new batch of residents doing oncology for the first time.  Because I was a little more familiar with the patients I was able to help out with some of the history of the visit to get the residents up to speed.   

One of my new patients today experienced an acute methotrexate overdose over the weekend though he has not shown any symptoms yet other than a bump in his creatinine.  Whenever this happens, it's always on the weekend for some reason (Murphy's law right?).  His 24 hour methotrexate level was about 35 (the usual target is 1) and his creatinine jumped from 77 to 211 in a day (oops forgot that we use the metric system over here...that would be from 0.87 to 2.39), which got worse during the day.  

We're sort of stuck deciding whether the patient is sick enough to order the antidote because he hasn't shown any of the other toxicities yet.  The common MTX toxicities would be nephrotoxicity, mucositis, diarrhea, myelosuppression, and pneumonitis and he only has one of them.  The problem is there is no supplier in Singapore that stocks the antidote, Voraxaze (glucarpidase), which can dramatically bring down the MTX level in a day by cleaving the drug.  If we were to order it, it would take 24-48 hours to arrive in Singapore from the UK.  In the meantime, we're trying as hard as we can to hydrate and diurese him in the hopes that he'll start to clear the drug on his own.  We'll see what happens tomorrow.  Stay tuned!

Random Food Pics 4

It's that time again!  The weekend means it's time for another food adventure although I got started a little earlier this week when my preceptor took me to Korean BBQ...all you can eat for $17 USD!  Then some of my pharmacy friends really wanted to have Bak Kuh Teh (signature Singaporean pork ribs soup) at another famous outlet so we were able to take a 2 hour lunch for that...delicious!

All You Can Eat Korean BBQ

Bak Kuh Teh with Assorted Veggies - free refills on the soup!

BBQ Chicken Pizza

Smoked Salmon Rosti (Swiss Hash Browns)

Fried Calamari

Baked Potato w/bacon bits, sour cream and mint pesto

Smoked Salmon Crepe

Original Laksa in far eastern Singapore - took 40 mins to get here but well worth it!

 

First Presentation

I was asked by one of the attendings to give a presentation on the pharmacology of the drugs to treat CMV because we had 2 patients this week whose CMV seemed to have been reactivated post chemotherapy.  For one of the patients, the side effects he experienced with the initial treatment (valganciclovir) got so bad we had to switch him to the second line treatment (foscarnet) which has potentially worse side effects for his kidneys but would not affect his white blood cells as much; we really needed to rebuild his immune system quickly because he was deteriorating rapidly.  As of Friday afternoon we had to transfer him to the ICU so I hope he makes it through the weekend.

So I found a very cool feature of blogger that allows me to post my slides so here is my presentation if you're interested:


 

Inpatient Pharmacy

This past week I had the chance to see how the inpatient pharmacy operates at SGH.  There is only one inpatient pharmacy that takes care of the entire 1600 bed hospital so of course there are a lot of pharmacists here.  My preceptor told me at any given time there are usually about 40 staff pharmacists with clinical pharmacists coming down to the pharmacy to help during the peak discharge hours.  The pharmacy is actually partially decentralized with a separate building across the street that is used to make aseptically prepared medications and TPNs.  Another group of inpatient drug info pharmacists sit in this building as well and somehow, every day the communication back and forth between the main, the satellites, and the floors runs smoothly.  A lot of hospitals also have a tubing system to get meds up to floors quickly but here there is an overhead trolley system that travels throughout the complex to deliver anything that fits inside a container the size of a cash box.  The system is quaint and not very fast so a lot of techs will walk over stat medications.  The hospital is very concerned with cost cutting which I think could be why only part of the hospital is air conditioned and there is still no full EMR despite being the largest institution on the island.  In some respects the healthcare facilities here are outdated but the teams still practice solid evidence based medicine which is impressive given the limitations.