Yesterday I completed my duty as a juror in an eight-day civil trial involving a negligence claim against two cardiologists in a community hospital. The experience offered a much different view of hospital operations than I usually get from interviewing CIOs and CMIOs for Healthcare Informatics. Those eight days were spent hearing testimony, but also reviewing dozens of pages of patient records and clinical notes.
As my fellow jury members and I focused on the facts of the case, I also reflected on the mix of electronic and paper records and their impact on preserving the clarity of what the providers were doing at the time, as well as their communications with each other. Although I believe the question of paper vs. electronic documentation was not a key issue in this case, it was interesting to see some of the pluses and minuses of paper documentation and why computerized documentation might be preferable, even though the transition obviously is difficult and the early iterations of the documentation software might not meet provider needs.
First, a little about the case: For the purposes of this blog post, I won’t go into too much detail, but the case involved a patient who developed a bleed and went into shock following cardiac catheterization. After lengthy efforts were made to resuscitate him and stop the bleeding, he was eventually transferred to a nearby trauma center where he underwent surgery, which had many complications of its own and which have impacted the patient to this day.
A central question in the trial was whether the cardiologists expedited an imaging study to identify the severity of the bleed quickly enough to speed up the transfer to the trauma center. As the patient’s blood pressure was being stabilized, a worrisome EKG in the intensive care unit led the cardiologists to re-examine a stent placed in the patient’s heart earlier that day, which took approximately an hour, before taking him to the CT scan (the stent was OK). After listening to hours of expert testimony, the jury decided that the physicians had not been negligent. (One defense attorney noted that if the physicians had failed to re-examine the stent and the patient had died of a heart attack, we would have been in the courtroom hearing a case about negligence for not paying enough attention to that EKG.)
Most of the clinical documentation in the case involved handwritten notes by residents and nurses. The portions of the record that were electronic and time-stamped seemed to head off some debates and clarify the timeline for everyone involved. (For instance, the EKGs are time-stamped and the systems themselves provide an automated preliminary diagnosis before the cardiologist reads it.)
While some of the handwritten documentation was clear and precise, other entries had gaps or involved ambiguities or provider preferences. When asked about the time of particular notes, physicians explained that some residents choose to write the time they first encountered the patient, while others write the time that they are signing the note. One resident scribbled a rapidly dropping blood pressure reading next to a normal one at the top of a page as she was completing a physical assessment. The time of the second reading was unclear.
There were debates about whether a resident who wrote: “spoke to attending” meant the attending physician on the case or his own attending physician in his specialty. The same doctor numbered the things that were planned next for the patient. One attorney argued that this was meant to be a list of priorities, while the defendant physicians said the numbered list was not meant to be an order in which the events were to happen, but merely a bulleted list of what needed to be done. (The doctor who wrote that note was not called to testify.)
One critical care nurse did not write a note about her actions at the time of the incident, and was asked to do so by the hospital nine months later. She remembered her actions, but unsurprisingly got the times wrong.
There was criticism leveled at the physicians for failing to communicate all the details of the patient’s symptoms to the entire care team at all times. It was not clear what a realistic expectation is for that type of information exchange. Perhaps electronic documentation helps providers get more frequent updates and better communicate in a rapidly changing situation.
It appears that in an emergency situation such as this, documenting everything that is happening to a patient is an even more difficult task than when providers have more time to assess the situation and write notes and orders.
All of this takes me back to a presentation I saw at last year’s AMIA conference by Peter Embi, M.D., Vice-Chair of the Department of Biomedical Informatics and chief research information officer of the Ohio State University Medical Center. He described a recent study he led at five Department of Veterans Affairs facilities. What their focus groups found was that the current clinical documentation systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated “paper-chart” paradigm.
In light of my jury experience, it has been interesting to go back and read some of the perceived pros and cons of computerized documentation described in the interviews for that article.
For instance, one administrator complained that providers were using the documentation as a form of messaging. ‘In audits, unfortunately, when we're auditing we see that, sometimes, the progress notes are used as Outlook (e-mail), where they're discussing things amongst providers to each other. For instance, they will use the progress note and say, ‘<Name>, what do you think about this for Mr. <Name>'? And, then they send an alert to her to look at this. ‘Well, I think, maybe, we ought to think about this', and you send it back saying, ‘Would you call so-and-so, and remind them to get this lab work, change their pills?'…'
One nurse did not like the way the system delivered error messages: ‘You spent 30 minutes entering information and you think you have everything; you'll hit ‘enter' and it'll pop up with a little text box that says ‘you missed something'. But it doesn't identify what you missed and so then you'll spend another 15 minutes going over it again and then you still can't find it, so then you have to get somebody else to come and look at it to see if they can spot the thing that you missed.”
The authors noted a “tension between the perspectives of clinicians and administrators was especially evident in discussions of control functionality inherent in the computerized provider documentation system. In general, the administrative group valued the completeness afforded by templates, while the practitioner and nurse groups complained that while templates could help facilitate documentation, restrictive templates generated less informative documentation than free text.”
Read the whole article here: