Dr KK Aggarwal
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A
63-year-old retired worker was referred to a cardiologist (Dr C) after his
ECG showed atrial fibrillation, who believed the fibrillation to be of recent
onset and put him on amiodarone. Over the next month, amiodarone was reduced
as sinus rhythm had normalized. Six months later, the patient visited his PCP
and Dr C with isolated complaint of a rapid heart rate and a full feeling in
his chest. He continued to take amiodarone and daily aspirin.
Six
years later, the patient visited his hematologist for raised hemoglobin and
complained of occasional epigastric pain with activity during one visit. The
hematologist asked the patient to see Dr C thinking that the symptom could be
related to the heart. A year later, the patient visited Dr C, who put the
patient on a Holter monitor and the next day had him perform a 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.
The patient was considered stable and advised to return after 3 months by Dr
C.
But,
the patient suffered an embolic stroke two months later leading to weakness
in the left arm and leg and facial droop. 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 that 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 H&P 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.
(Source:
Gordon T. Ownby. Malpractice case: dangers when transitioning to
electronic records - Medscape - Jul 23, 2019)
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Electronic records offer
several advantages such as quick and easy access to patient data as information
is available at the touch of a finger or a click of mouse;
improved efficiency and quality of care by minimizing risk of errors. They also
save on storage space.
But, there are downsides to
technology; most important being privacy and security violations, inaccurate or
incomplete information, all of which pose potential risk of medical
malpractice.
But, most importantly,
electronic records leave an audit trail i.e. a record of the changes that have
been made to a database or file.
An audit trail can be defined
as a “record that shows who has accessed a computer system, when it was
accessed, and what operations were performed” (Brodnik, Melanie, et
al., Fundamentals of Law for Health Informatics and Information
Management. Chicago, IL: AHIMA, 2009, 215).
Like the paper records,
electronic records too are subject to scrutiny; audit trails are asked for in
malpractice litigations even though they are not part of the patient records.
The Electronic Health Record
(EHR) Standards for India 2016 have outlined the principles of data change.
“The data once entered
into a health record system must become immutable. The
healthcare provider may have the option to re-insert/append any record in
relation to the medical care of the patient as necessary with a complete audit
trail of such change maintained by the system. Alteration of the
previously saved data is not permitted. No update or update like
command shall be accessible to user or administrator to store a medical record
or part thereof. Any record requiring revision should create a new medical
record containing the changed/appended/modified data of earlier record. This
record shall then be stored and marked as ACTIVE while rendering the previous
version(s) of the same record being marked INACTIVE. The data will thus in
essence become immutable. A strict audit trail shall be maintained of
all activities at all times that may be reviewed by an appropriate
authority like auditor, legal representatives of the patient, the patient,
healthcare provider, privacy officer, court appointed/authorized person, etc.
as deemed necessary.”
Medical records are the best
defense for the doctor. Poor records spell poor defense and no records mean no
defense.
World over, health care
establishments are changing over to electronic health records from paper
charts. But, the information has to be manually fed in the software and there
is the risk of information being lost or missed out during the transition process.
Therefore, it is safer to also
maintain paper records, as a safeguard, until the new EHR system is fully
functional and/or until people get used to the new system.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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