Case study: Monday morning: The week gets off to an interesting start as patient Mark Bayne reports to the clinic. Bayne is a contact lens wearer who…

Case study:

Monday morning: The week gets off to an interesting start as patient Mark Bayne reports to the clinic. Mr. Bayne is a contact lens wearer who comes in with a red eye. His right eye had been bothering him for a week, and it was slowly getting worse. When examined, the right eye exhibited perilimbal injection of the bulbar conjunctiva and a corneal defect. The corneal defect was a dense anterior stromal corneal infiltrate with diffuse borders overlying a subtle focal area of corneal thinning 2mm eccentric to the visual axis. Using the electronic health record to look up Mr. Bayne’s previous eye notes you determined that his right eye was clear at his last examination two months ago.

Your electronic health record’s Infobutton application suggested several relevant topic information links in response to the information you input into the medical encounter. Selecting the infobutton corresponding to fungal keratitis (one of your primary rule outs), you are reminded that using a simple KOH +CFW smear preparation for the light microscope as well as culturing in Sabouraud 2% glucose-agar (without cyclohexamide) would yield the best chance of detecting fungal keratitis. Armed with this information you take the correct corneal specimens prior to treating the patient, as medication might contaminate your results. As you write the patient’s orders in your EHR a reminder pops up indicating that this patient is due for a periodic visual field examination in one month to monitor for glaucoma. You mention this to Mr. Bayne and prior to leaving he sets up that appointment hopeful that the current malady will have resolved by then. Having taken your specimen and recorded your results you send the patient off to the corneal specialist confident that your notes will be available to her. The next day Mr. Bayne is seen by the corneal specialist, and the results from the laboratory of your initial scraping indicate that with light microscopy hyphae were detected. Although the results of this testing were sent to you they are available to the corneal specialist using a compatible medical record and the regional health information exchange (RHIO). As a result the specialist is able to move forward with the most up to date information for the patient improving patient care.

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Your lab order for Mr. Bayne and EHR notes are available through the RHIO to those entities with permission to view them. Governmental public health agencies monitor lab testing and other early indicators of disease outbreak. Public health surveillance picked up on your lab order. Tuned to detect increases in particular lab tests the software noted there has been an increase in your state of the use of corneal cultures utilizing fungal specific Sabouraud’s medium this past week, (normal incidence of 3 to 4 per week up to 10 this week). This increase in the number of these cultures alerts public health officials to the possible increase in fungal infections of the cornea. When the state agency matches the lab orders with the patients’ address information obtained from their providers’ EHR they are able to feed this information into a Geographic Information System which pinpoints the location of the patients on a map such as seen in figure 2. In this case, the map makes it obvious that the problem is isolated to the area surrounding Yonkers, New York. An alert is then sent out to eye doctors, primary care doctors and laboratory personnel in this area informing them of the situation and asking for them to report episodes of suspected fungal keratitis. As a result of this request an outbreak is detected and its source is located resulting in the recall of an isolated lot number of a particular contact lens solution.

Discussion question:

 

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