Friday, August 23, 2013

Electronic charting, tracking and malpractice lawsuits

A recent article on called "Medical charting errors can drive patient liability suits" led with a case involving a bad outcome after coronary artery bypass surgery. The plaintiff's attorney alleged that the doctors did not review the patient's lab results or x-rays because they did not specifically say so in the medical record.

The article quoted a defense attorney who said, "By the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked at that,' but there's no charting to back it up.” 

Unless there is something very unusual about the electronic medical record (EMR) used by the doctors in that case, there should be a very easy way to determine if they viewed the results in question.

A feature of every EMR that I am aware of is that each time a chart is accessed, the EMR records who accessed the record, where they accessed the record from, what they looked at and for how long they stayed on a page down to the second. It is like an electronic fingerprint with time included.

When I was a surgical department chairman, I had many opportunities to see how this worked. 

For example, I was asked to review a situation in which a resident failed to call for help with a patient who was crashing in the ICU. An arterial blood gas showing severe metabolic acidosis was not acted upon on a timely way. The resident said that the nurse did not report the critical blood gas result to him after the lab phoned it to her. This could not be verified, but the EMR showed that he had seen the result some 30 minutes before calling his senior resident.

Another case centered on an allegation by a gynecologist that a consultant surgeon failed to respond promptly to a call to assist with a bleeding patient in the operating room. The EMR revealed that four days after the case, the gynecologist had altered her operative dictation to make it appear that she had called for the consultation much earlier in the course of the surgery than what actually had occurred.

A surgical resident looked at a chart of a patient who did not have a surgical problem and was not on his service. She denied having accessed the record. When it was reviewed, the EMR showed that she had looked at 9 separate sections of the chart and had spent more than 10 minutes doing so.

As is true of many reports about malpractice trials, important details about the heart surgery patient's case are lacking. But surely the defense attorneys must have known that the EMR could be searched to see if and when the doctors in question looked at certain portions of the chart.

If all medical, nursing and ancillary staff members are not aware of the tracking features of EMRs, they should be. This is the same type of tracking that catches unauthorized personnel who peek at the chart of a celebrity or other prominent patient in the hospital. 

Note the example of the recent Boston Marathon bomber who was hospitalized. Staff who were not involved in treating him were repeatedly warned not access his EMR. 

Consider yourselves informed. Big brother is watching.


artiger said...

Another thing I wonder about is if one accidentally looks at the wrong chart. It's happened to me more than once, as our system posts all of the inpatients in one window, and I've clicked on the wrong one before. I've even typed in progress notes on the wrong person. Our X rays are similar, I've clicked on the wrong name more than once. When this happens, should I write down the date and time of my mistake, just in case someone comes along a few years later and tries to hit me with a HIPAA violation?

Libby said...

I agree with you about the attorneys should've known about the tracking. Even the system our public library used for staff work tracked our access and what we did while on it. A few of us did not like the 'big brother' aspect (trust issues with management or what!) and revolted by not logging off after each use--we had access to 4 computers to do our processing of material. Besides, logging on/off every time we changed computers would be a waste of time-for OUR work. It could give management information about when & how long we were on, what & which library materials we actually processed, what programs we accessed--internet usage also, & most likely which sites we visited. Even with home computers we leave 'footprints'...methinks that attorney was either computer illiterate or deliberately ignoring that aspect of the system.

As a patient it was nice to realize that my doctor had a note flagging up to discuss something with me at my Aug whatever visit & when he called me to discuss my X-ray results (fracture-cycling crash 2 wks ago) he knew the date I was coming in next because it was on the EMR! With paper charts they would need to ask or have a sticky note about the discussion topic.

Anonymous said...

OUCH! I feel for both sides. I can imagine that some people forget - especially if you have 5 people code blue'ing on you - that they saw something in a chart. I can imagine there are people who deliberately lie. Just like with patients. I've forgotten to tell my doc things (even with notes in hand, not like I'm not trying to dot i's and cross t's) and does that make it harder for them to dx me? Yes. Does that mean I lie? No. Do I have people I know lie to docs outright? Yes.

As someone said in the comments above, you can pull the wrong file or be looking at wrong information or the patient you saw 1 hour earlier and bring them up vs. the one you meant.

I've also seen some obvious voice transcription errors, never found out what the doc meant. This makes it hard for docs going behind them. Please review notes for your fellow health professionals!

I think the hardest part is when there are obvious differences between what one doc says and another doc, or when the record is so general as to be useless. I've seen getting blamed for something that happened a year ago (wonder why it got brought up now?), and then no documentation for other items. If you say I screwed up, but I say, and the record shows, no documentation, by your own rules: it didnt happen. Meaning don't say I didn't follow your instructions when its not listed. Or else how do you want to appear to a fellow healthcare professional?

Skeptical Scalpel said...

Artiger, I too have written a note on the wrong patient. Someone from IT should be able to delete it for you. If you have it deleted in a timely way, it should not be a problem. The other thing you can do is write another note explaining what happened. If you accidentally open the wrong chart and immediately exit, there should also be no problem. If you linger = problem.

Libby, good points. However, leaving oneself logged in could cause a problem if a co-worker than looks at the EMR of a celebrity. It would be tough to convince people that you didn't do it.

Anon, lots of people don't proofread their notes or dictations. Some can be pretty funny. I have blogged about it -

And yes, some doctors might lie. Just because it's in a record does not mean it's true even though that is an assumption that many people make.

Tracey said...

Metadata- those fine computer trails of detail- can be your best friend or worst enemy!

Libby said...

Re: staying logged on: I agree that within the context of a EMR or other heavily confidential system that staying logged on could get you into deep trouble-or you get others into trouble (if you are unscrupulous). Within our public library work room, it was not an issue, but it still left us open to being scrutinized by management if, say, pornography was being accessed under someone's log on, or they just wanted to nit-pick. As the staff turned over, I became cautious when a certain staff member was on shift.

When I worked for our provincial health services, even though I did not have access to EMRs or other patient files, I still had access to my boss's highly confidential research material and so I made sure if I wasn't at my desk I was logged off.

The electronic paper trail is harder to shred than Nixon's Watergate files.

Skeptical Scalpel said...

Tracey and Libby, this is exactly why I wrote the post. I am not sure that people understand how comprehensively they can be monitored.

Merrick Kennworth said...

Electronic Charting is not any different than the old paper method of charting when it comes to a couple of issues. First is the information is only as good as the data that was imputed. Errors happen regardles of using pen and paper or a computer. Second is that the information is only good if used. Come on, being told you had to look at X-rays before a procedure, I would think that would happen even if you had all ready looked. The hole idea here is to speed up the time and access to information, it’s still up to us to do are part and blaming it on a device or software seems to me a little like saying “the dog ate my homework”.

Skeptical Scalpel said...

Merrick, thanks for commenting. I agree with some of your points. However, in the context of the post, you could look at a paper chart and no one would ever have known you did so. That's not the case with an EMR.

There's much more data in an EMR, and a lot of it is not looked at by anyone. See a previous post of mine --

It's also easier to "upcode." See another post --

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