DC Medical Malpractice & Patient Safety Blog

Electronic medical records make it easy -- too easy -- to document that a doctor or nurse has performed a model examination of a patient. One click, and the empty slots fill in the results of a normal exam from head to toe. But was that thorough exam really done?

Copy and paste is another shortcut offered by electronic records that saves a lot of typing, but that can allow errors in a record to perpetuate from shift to shift and day to day. All it takes is a single mistake in, say, the past medical history taken of a patient when admitted to the hospital, and every other provider copies the error, with sometimes terrible results, as when the initial history taker, and then everyone else, misses an important disease that the patient has had.

An op-ed in the New York TImes highlights the downsides of electronic documentation. Leora Horwitz MD, a Yale medical professor and internist, says she wouldn't go back to the bad old days of handwritten medical records, but the new electronic records carry some dangerous temptations for busy providers and also make care more expensive. Dr. Horwitz writes:

Of course, you shouldn’t click those buttons unless you have done the work. And I have many compulsively honest colleagues who wouldn’t dream of doing so. But physicians are not saints.

Hospitals received $1 billion more from Medicare in 2010 than they did in 2005. They say this is largely because electronic medical records have made it easier for doctors to document and be reimbursed for the real work that they do. That’s probably true to an extent. But I bet a lot of doctors have succumbed to the temptation of the click. Medicare thinks so too. This fall, the attorney general and secretary of health and human services warned the five major hospital associations that this kind of abuse would not be tolerated.
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In short, reading the electronic chart has become a game of looking for a small needle of new information in a haystack of falsely comprehensive documentation and outdated, copied text. Why do we doctors do this to ourselves? Largely, it turns out, for the same reason most people do most things: money.

Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down.

Of course, when you have an honor system for how much a doctor is paid, the documentation requirement is a natural check-and-balance to make sure the time really was spent with the patient. Now we need a way to make sure that point-and-click medicine and copy-and-paste medicine really serve the patients' interests.

This reinforces my advice to all patients: Read your own medical records. You may be surprised what you find there. You will always be educated, and sometimes you can catch flagrant errors, whether they are due to copy-and-paste issues or other problems. Last month's newsletter has more on how to get and read your own medical records.

A Maryland-based medical staffing agency is at the center of allegations that it placed a rogue radiological technician into a number of hospitals in Maryland and other states. The technician is believed to have infected dozens of people with hepatitis C.

Maxim Staffing Solutions, a national firm with headquarters in Columbia, Maryland, placed technician David Kwiatkowski into three Baltimore hospitals: Baltimore Veterans Affairs Medical Center, Johns Hopkins Hospital and Maryland General Hospital, and also at Southern Maryland Hospital in Clinton, between 2008 and 2010.

Kwiatkowski was arrested in late July in New Hampshire after he was caught in a hospital stealing narcotic drugs that were intended for patients. He now faces federal charges.

The four Maryland hospitals are sending notices to several hundred patients to get testing for hepatitis C, a viral infection of the liver that, in bad cases, can lead to liver destruction and need for transplant.

Whether Maxim had reason to suspect the technician's danger to patients has yet to be determined. Lawsuits are likely against Maxim and another staffing agency that sent him to hospitals in as many as seven states in the last few years.

It's also unclear whether any of the Maryland hospitals had an inkling of problems with the technician. But at least two other hospitals, the prestigious UPMC Hospital in Pittsburgh and the Arizona Heart Hospital in Phoenix, fired Kwiatkowski after finding him with narcotic drugs.

A couple of months ago, we wrote about the sloppy, widespread clinical practices that put patients at risk of contracting hepatitis C, but this case, it appears, goes well beyond carelessness.

Maxim Staffing is alleged to have sent Kwiatkowski to UPMC in the spring of 2008. There, he was observed by another employee placing a syringe containing fentanyl, a Schedule II narcotic, in his pants. He replaced the missing syringe with another containing another liquid. Management confronted him, found three empty syringes with fentanyl labels on his person and an empty morphine syringe in his locker. His urine tested positive for fentanyl and opiates.

He was fired.

But UPMC did not report the theft, use or diversion of its controlled substances to any government agency or law enforcement authority. The technician was free to practice his alleged crimes elsewhere, and Maxim placed him in a matter of weeks into the first of four Maryland hospitals where he worked.

By the time he tested positive for hepatitis C in June 2010, dozens of patients who had undergone cardiac catheterizations at the hospitals that had employed him had been exposed to a common strain of hepatitis C. Most of them have learned only in recent months of their diagnosis. Based on this information, thousands of cardiac catheterization patients at hospitals where he worked are being tested for hepatitis C.

As noted in our backgrounder, hepatitis C can cause liver failure. The blood thins, and patients bleed easily. In the worst cases, called fulminant hepatic failure, the brain swells and the patient goes into a coma. About half of these patients die without an emergency liver transplant.

In July, a warrant was issued in New Hampshire for the technician’s arrest for acquiring a controlled substance by misrepresentation, fraud, forgery, deception or subterfuge, and for tampering with a consumer product with reckless disregard for the risk he posed to others of death or bodily injury, and for the serious bodily injury that has befallen others.

It’s shocking enough that a drug addict in a position to contaminate hospital equipment with a deadly virus not only would be hired and rehired and rehired without regard for his illness or the harm he created for others. But that the hospital and the staffing agencies that knew about the risk failed to report his crimes is unconscionable.

The tech was placed by Maxim into the four Maryland hospitals AFTER his firing from the Pittsburgh hospital. What excuse does Maxim have for failing to find out what had happened in Pittsburgh and for enabling his further crimes? We will find out in the coming lawsuits.

We do know this much. As a result of this infected technician being given access to patients in seven states across the country, dozens of people face a dire infection, and countless others are left to wonder if and when it will strike. With a hep C diagnosis comes significant costs for treatment and care, the possible loss of livelihood and maybe even life itself. And none of it had to happen.

Electronic health records (EHRs) hold much promise for reducing medical errors and improving quality of care, but the prospect that patient advocates can use EHRs to do an autopsy of where a patient's care went wrong has some in the medical industry sounding an alarm.

Last week a story (actually a press release, on closer scrutiny) in the Wall Street Journal's Market Watch talked about "Crippling Access to Physician's Actions" allowed by tattle-tale Electronic Health Records. Among the horrors described by IT consultant Dr. Sam Bierbock:

EHRs ... can also be audited to examine how long it took them to act after an abnormal lab result came in, if the doctor checked on on-line references before making a clinical decision, what was said in every email and how long the doctor took to respond, and even how long the doctor looked at a screen or scrolled down to read an entire document.

And this is a bad thing?

Fortunately there are patient advocates in the medical informatics industry. One is Scot Silverstein, MD, of Drexel University, who trained as a doctor in intensive care units, which have heavy demands for up-to-the-second monitoring information on the desperately ill patients they care for. Dr. Silverstein wrote a well-informed blog post on the real problems with EHRs and why it won't wash to make plaintiff attorneys and malpractice lawsuits the whipping boy for the industry's troubles.

Our firm represented a patient's family last year in a particularly tragic malpractice case where we used the hospital's "audit trial" of EHR records to show that a nurse was claiming to be in two places at one time. Her neglect led to the stillbirth of our family's child.

The alarm of IT consultants like Dr. Bierbock over the ease of auditing health care brought about by EHR's is really a false alarm. Yes, there will be closer scrutiny of medical decisions. But audit trails will lead to more accurate understanding of what happened in any tragic injury, and that should lead to better care for all.

First published on Technorati.

As health-care expert Lisa Zamosky points out on WebMD, you might not be able to control medical costs, but scrutiny of your medical bills can help you save money. The key, she says, is knowing when and how to take action.

Here are four things to watch.

1. Always review your medical bills. They’re notoriously riddled with errors. Be mindful of even minor charges, especially when it comes to hospital care. For example, one person reported that her grandfather was alone in the ICU and intubated (had a breathing tube and was unable to speak) when he was billed for making phone calls at 4 in the morning.

Make sure you’re billed only for the days you were in the hospital, and that there are no duplicate charges for things such as doctor visits and tests and medicine you didn’t receive. If you find errors or discrepancies, immediately contact your doctor’s office manager or billing department, or the hospital where you received care.

2. Confirm that your insurer paid the provider(s). If doctors or hospitals fail to bill the insurance company, if they do so improperly and/or you have more than one type of insurance, confusion can reign. Before paying anyone, find out if your providers have billed the proper insurance company for the procedure you received, then determine whom and how much the insurer(s) paid.

3. Don’t accept an insurance company’s denial of coverage without a fight. “No” doesn’t always mean “no”; sometimes it means “How willing are you to fight?” Thanks to the national health care reform of 2010, everyone has the legal right to appeal coverage denials. If the insurance company rules against you, it must explain why and provide information about how to obtain an independent review of your case. This right does not apply to grandfathered health insurance plans, which are explained here.

There’s evidence that appeals work: The Government Accountability Office (GAO) found that nearly 6 in 10 health insurance appeals were decided in favor of the patient. About 4 in 10 independently reviewed appeals were reversed in the patient’s favor.

4. Negotiate. Most people are uncomfortable haggling over prices, whether it’s for heirloom tomatoes at the farmers’ market or health services from your doctor. But prices for medical care are not rigid. If you need a break, if you believe the cost is too high and especially if you have a high deductible or lack insurance altogether, seek financial relief directly from the source. Your case is stronger if you research in advance fair prices for the relevant medical service in your area. Many health insurers have website pricing features. The Healthcare Blue Book is another pricing resource.

As the saying goes, keep your friends close and your enemies closer.

Not that we know for sure that behavioral economist Dan Ariely considers pharmaceutical manufacturers “enemies,” but we know he’s onto their practices that are not exactly in the best interest of patients. He and a colleague recently had dinner with a few pharmaceutical sales representatives to find out the tricks of their trade, which is getting doctors to prescribe their companies’ drugs.

Trick No. 1: “One of [the reps] told us a story about how he was once trying to persuade a reluctant female physician to attend a seminar about a medication he was promoting. After a bit of schmoozing, she finally decided to attend – but only after he agreed to escort her to a ballroom dancing class.” A fine example of, Ariely says, if-you-scratch-my-back-I’ll-scratch-yours.

Trick No. 2: “[B]ring meals to the doctor’s office. … [O]ne office even required alternating days of steak or lobster for lunch in exchange for access to the well-fed doctors.”

Trick No. 3: “When the reps were in the physician’s office, they were sometimes called into the examination room (as ‘experts’) to inform the patients about the drug directly. And the device reps experienced a surprisingly intimate level of involvement in patient care, often selling medical devices in the operating room, while the surgery was going on.” (Comment by Patrick Malone: What's really shocking is that these sales reps have at most a bachelor's degree and a few weeks of training from their employers.)

So, Ariely asks, what should be done about this shocking insinuation of commerce into medicine? “[R]ealize that doctors have conflicts of interest. …[P]lace barriers that will prevent this kind of schmoozing, and keep reps from accessing doctors or patients.”

And have dinner with somebody else.

It’s increasingly common that when you visit the doctor you’ll be seen first, and maybe exclusively, not by the person with the M.D. degree, but by another trained medical professional. According to a report commissioned by the Centers for Disease Control and Prevention, in 2009 nearly half of all office-based physicians practiced with nurse practitioners (NPs), certified nurse midwives (CNMs) or physician assistants (PAs).

And these days, the presence of PAs in hospital emergency departments (ED) is growing. According to a report published in Renal and Urology News, PAs treat approximately 1 in 10 patients who visit EDs each year.

Physician assistants must complete an accredited education program and pass a national exam in order to obtain a license. As described by the U.S. Bureau of Labor Statistics, PAs practice medicine under the supervision of M.D.s. They are trained to provide diagnostic, therapeutic and preventive health-care services. They work as part of a health-care team, taking medical histories, examining and treat patients, ordering and interpreting laboratory tests and X-rays and making diagnoses. They treat minor injuries, record progress notes, instruct and counsel patients, and order or carry out therapy. They may prescribe certain medications.

Some physicians have been uncomfortable with what they believe is a professional or legal threat posed by PAs. But that seems to be a minority view.

A study in the Journal of the American Academy of Physician Assistants sampled 1,000 emergency physicians in 2004 and again in 2009 about their perceptions of PAs in the ED. In 2004, about 720 respondents disagreed or strongly disagreed that PAs are more likely than physicians to commit medical malpractice, and 680 did so in 2009. In 2004, some 840 disagreed or strongly disagreed that PAs were more likely than M.D.s to be sued for medical malpractice; some 820 responded similarly in 2009.

In the five years between 2004 and 2009 the number of physicians who reported practicing with PAs increased by 1 in 4. And the number of physicians who believed the presence of PAs diminished patient waiting times in the emergency room grew by 13 in 100; the number who say PAs boost patient satisfaction rose by 1 in 10.

“Most emergency physicians agree that the increased utilization of PAs in the ED may improve patient communication, decrease wait times, increase patient satisfaction, and therefore decrease malpractice risk,” the authors wrote.

“[A]s physicians gain both clinical experience and experience working with PAs, their perception of malpractice risk imposed by the PA in the ED significantly decreases.”

The CDC report outlined where skilled medical helpers are found most often:

• Primary care physicians were more likely to have NPs, CNMs or PAs than physicians of other specialties.


• Physicians in larger and multi-specialty group practices were more likely to work with NPs, CNMs or PAs than those in smaller and single-specialty group practices.


• Older physicians were less likely than middle-aged physicians to be in practices that included NPs, CNMs or PAs.


• Physicians in practices with a higher proportion of revenue from Medicaid and a lower proportion from Medicare were more likely to work with NPs, CNMs, or PAs.

The CDC study noted that the Affordable Care Act -- the health-care reform bill passed by Congress last year -- includes funding for PA education in primary care, so more of those practices probably will be employing them. Because PAs often take more time with patients than the in-and-out, assembly-line experience that’s all too familiar in the doctor’s office these days, this bodes well.

Who runs a hospital better, a physician or a businessperson? And which is better for patient safety and healthy outcomes?

As reported in the New York Times, the conventional wisdom that doctors should focus on patient care and managers should run the infrastructure was challenged by a study in the journal Social Science & Medicine.

Of the nearly 6,500 hospitals in the U.S., only 235 are run by physician administrators.

In a review of 300 top-ranked U.S. hospitals specializing in a variety of disorders, "overall hospital quality scores were about 25% higher when doctors ran the hospital, compared with other hospitals," The Times said. "For cancer care, doctor-run hospitals posted scores 33% higher.

Study author Dr. Amanda Goodall said the finding was consistent with corollary research showing that research universities perform better when led by outstanding scholars and that basketball teams perform better when led by former top players.

Goodall said the results may reflect the fact that doctors truly understand “the core business of health. ... M.D. CEOs are more likely to prioritize patients because patient care is at the heart of their education and working life as a physician. When it comes to making hard budgetary decisions or rationing choices, M.D. CEOs may be able to make more informed decisions.”

The study results, Goodall pointed out, show only an association between high hospital scores and doctor CEOs; they do not prove that doctors make better leaders. Maybe top hospitals are more likely to seek out doctor leaders; maybe top doctor managers seek out the best hospitals.

Bottom line: The best hospitals seem to choose physician executives, and lower-ranked hospitals usually have managers with a business or administrative background.

That's something for patients to consider if they have a choice of hospital facilities.

In a stark reminder that the practice of medicine is a business as well as a service, a new study has proved what doctors have been saying for years: Meeting the paperwork needs of insurance companies costs U.S. doctors in a big way.

According to the study published in Health Affairs, U.S. docs pay an average of nearly $83,000 per year "in time and labor interacting with multiple insurance plans about claims, coverage, and billing for patient care and prescription drugs."

These costs, the study concludes, hit hardest at practices with only one or two physicians.

Researchers compared U.S. medical practices with those in Ontario, Canada. "We estimated physician practices in Ontario spent $22,205 per physician per year interacting with Canada’s single-payer agency — just 27% of the $82,975 per physician per year spent in the United States," they wrote. "U.S. nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans — nearly 10 times that of their Ontario counterparts."

Canada, of course, has a single-payer health-care system; U.S. medical practices often must secure prior authorizations and deal with several insurers with different billing requirements, requiring a greater investment of staff resources as well as time.

Of course, sometimes preliminary measures save money and guard against inappropriate care. And the U.S. system affords consumers more choices.

But the researchers said if administrative costs for U.S. physicians were the same as the Canadians, collectively they would save as much as $27.6 billion a year. They concluded that electronic filing would make the U.S. process more efficient.