Physicians in the operating room know that “alarm fatigue” is a real thing that must be taken seriously. With the advent of electronic health records, office-based practitioners must also fight complacency with system-generated reminders for regular patient testing.
The earliest records of the patient’s care with the medical group for Dr. FP, a family practitioner, showed a “Patient Profile” that displayed hand-filled dates for mammograms in 2006 and 2010, and cholesterol and other labs in 2006. The health screening field in the profile for sigmoidoscopy was blank for this period.
In 2011, the patient was hospitalized for abdominal pain after a laparoscopic cholecystectomy. The hospitalization included an ERCP and her discharge summary noted a resolved ileus, resolved pancreatitis, erosive duodenitis, hypertension, and diabetes. A review of the hospitalization shows no evidence of a colonoscopy or of any suspicious masses in the colon.
In Dr. FP’s first visit with the then 73-year-old patient following that hospitalization, Dr. FP addressed complaints of bronchitis, hypertension, and hyperlipidemia. The patient’s visits to Dr. FP and the primary care group over the next year addressed the hypertension, cholelithiasis, mammogram testing, osteoporosis testing, and likely mild diffuse fatty liver disease. At one point in that first year, Dr. FP’s chart includes a health plan-generated page titled “Selected Member” with a “Quality Measure Data” box identifying “COLO SCRN, GLAUC SCRN.” That record for that visit shows no discussion with the patient on colon screening or any such order for the patient.
The patient continued to see Dr. FP for various complaints and follow-ups. Despite the “Quality Measure Data” sheets noting colon screening (among other tests) being included in the charts for those visits, no colon screening tests were ordered. At one point, Dr. FP’s orders included “Screening for malignant neoplasm, colon” with a fecal globin by immunochemistry to be performed. That collection was normal. The form for “colo scrn” was again included in the chart for that visit but no colonoscopy was ordered.
The patient continued to visit Dr. FP and his partner at the medical group several times a year for various complaints for another six years. The records show no discussion with the patient for a colonoscopy. On visits over several of those years, identical language is used in Dr. FP’s EHR chart to describe a review of systems indicating abdominal pain and bloating yet (incongruously) an exam stating the abdomen is non-tender with no masses and no hepatomegaly.
Some eight months following her final visit to Dr. FP, the patient went for a well-woman exam at a different medical group after moving to a new town to be closer to a daughter. The attending physician noted that the patient needed a mammogram and was overdue for a colonoscopy.
Five months later, the patient visited the ER reporting diarrhea for three weeks. An abdominal and pelvis CT showed inflammatory changes in the transverse colon suspicious for colon carcinoma. A subsequent colonoscopy performed in follow-up found a friable polypoid apple-core lesion in the transverse colon taking up approximately 80 percent of the lumen. The biopsy revealed a poorly differentiated carcinoma and a CT-guided liver biopsy indicated metastatic adenocarcinoma, likely from the colon. Chemotherapy was initiated but the patient died two months later.
With no explanation available from Dr. FP for not ordering a colonoscopy or for not addressing the numerous chart reminders, the litigation initiated by the patient’s family was resolved informally.
Like an anesthesiologist disabling an audible alarm, an office practitioner who misses repeated EHR notices puts a patient’s safety at risk — and will face any litigation with an inflammatory medical record. Implementing office policies and systems to make sure that all EHR alerts receive a direct response is the place to start to avoid those risks.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.