In London’s Underground transit system, riders are warned to “Mind the Gap.” In other words, step carefully when going between the platform and railcar. “Mind the Gap” is also good advice to medical offices moving from paper to electronic records.
A 63-year-old retired worker saw Dr. C, a cardiologist, on a referral from his internist after an electrocardiogram showed atrial fibrillation. Dr. C believed the fibrillation to be of recent onset and started the gentleman on amiodarone. On several visits to Dr. C over the next month, the patient’s sinus rhythm had normalized and his amiodarone was decreased.
Visits to his PCP and to Dr. C some six months later included an isolated complaint of a rapid heart rate and a full feeling in his chest. He continued to take amiodarone, as well as daily aspirin. Various visits with his PCP over the next three years included discussions of atrial fibrillation and hypertension, plus other medical issues.
Six years on, the gentleman visited a hematologist for elevated hemoglobin. At one visit, the patient commented on occasional epigastric pain with activity. Concerned the symptom may be cardiac-related, the hematologist told the patient to return to Dr. C., which the patient eventually did, a year later.
On the patient’s return visit, Dr. C put the patient on a Holter monitor and the next day had him perform stress test/ECG. Dr. C’s exercise echocardiographic report authored that second day stated that the patient was “being evaluated relative to the current status of his coronary anatomy, left ventricular function, and cardiac rhythm.”
In that dictated report, Dr. C’s impressions were: no chest pain with exercise, no significant ST changes or arrhythmias, normal left ventricle systolic function and response to exercise, and no evidence of myocardial ischemia. Dr. C considered the patient stable and advised him to return in three months.
Two months later, however, the patient suffered an embolic stroke, which resulted in facial droop and weakness in his left arm and leg. The patient and his wife sued Dr. C, alleging that he did not appropriately manage his atrial fibrillation.
During his deposition by the plaintiff's attorney, Dr. C testified that his focus on the patient’s return to his office after the long absence was to rule out coronary disease, not to follow-up or rule out atrial fibrillation.
During that deposition, however, the plaintiff’s attorney showed Dr. C a History and Physical Report from the first day of that consultation. That H&P, an electronically generated record (with Dr. C’s electronic signature), stated at the outset: “The patient is a 70-year-old male who presents for evaluation and management of atrial fibrillation.” The H&P also noted the patient thought he was having a recurrence of the fibrillation twice or three times a week.
Apparently, Dr. C’s office was transitioning to electronic records at that time and the first day’s History & Physical was the only record relating to the patient’s care by Dr. C that was placed into the office’s new electronic record. That electronic record was produced in the course of a copy-service request for the patient’s chart made by the plaintiff’s attorney prior to litigation. Dr. C resolved the litigation with the patient informally.
Risk managers advise that when transitioning to electronic records, both systems should be maintained until the new system is fully functional. Also, a special implementation team should oversee everything that is going on for at least a two-week period. And, of course, special care needs to be taken during the transition to make sure that no particular entry gets orphaned.
Gordon Ownby is general counsel for CAP. Questions or comments related to this article should be directed to gownby@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.