Diving Deep in EMR – A Medical Malpractice Tale

A long-time client of ALN Consulting, a medical malpractice attorney, contacted ALN for assistance developing the defense in a suit brought against a primary care physician, Dr. A. White, for wrongful death due to reckless prescribing of controlled substances. Although we had collaborated with this client on numerous cases over years past, we soon discovered the circumstances of this matter were uniquely complex. As the ALN nurse analyst began the dissection of the medical records, she quickly discovered a 25 month history of “Dr. Shopping” by the decedent. This launched into a many month endeavor of diving deep into the abyss of the electronic medical records (EMR) systems of 24 different medical providers of care, 4 dentists, and 5 pharmacy chains with 17 locations…

At the time of her death in 2012, Ms. C. Smith was a 30 year old divorced mother of three. She left school after 9th grade and held various jobs over the years as a house cleaner, waitress, and salesperson. There was no record of employment after 2005. Ms. Smith’s past medical history included anxiety, depression, opioid dependency and surgery for gastric bypass, breast augmentation, and various dental procedures. In 2011, she underwent rapid anesthesia assisted detoxification in a treatment hospital specializing in chemical dependency.

On the date of her death, various reports indicated Ms. Smith was sitting outside by the family pool with her daughter. Her daughter went into the house for some time and when she returned, her mother was face down in the pool. Emergency medical services were summoned and upon arrival, performed CPR with ACLS protocols for approximately 45 minutes in the field. Ms. Smith was taken to a nearby hospital and was nonreactive to verbal, tactile, or painful stimuli upon arrival. She was stabilized and sent to the ICU on ventilatory and vasopressive support. Urine toxicology screen was positive for benzodiazepines, opiates, and tricyclic antidepressants. Radionuclide blood flow study to the brain showed no intracranial blood flow, consistent with brain death. Life support was removed and Ms. Smith was pronounced dead shortly thereafter.

Upon receipt of this case, ALN nurse analysts began an extensive review of what was represented to be the primary set of records documenting the care rendered in this matter. The records provided included visit documentation, phone triage and billing records for all care providers seen by Ms. Smith within Dr. White’s multi-specialty group. It was quickly evident that the records were incomplete, with unpredictable gaps in documentation.

During a conference with the attorney, Dr. White, and ALN, it was discovered that while Ms. Smith was under Dr. White’s care, the office had undergone a transition from a traditional paper charting method to an electronic medical records system. The medical records department was (and was still in the midst of) a mass scanning of all patient’s “old” paper records into the new EMR system for archiving. As the electronic system was still fairly new to the medical records staff, consultation with the office IT department was required in an effort to locate and extract the necessary missing patient information. During the month-long process of mining for the essential data, weaknesses within the old office system became apparent. The staff and providers had no real-time ability to monitor patient visits to multiple providers within the large practice and no method for cross-referencing active patient prescriptions for over-lap. Additionally, although the replacement EMR system was robust, it was determined the staff was under-utilizing its capability to address the issues identified within the old system.

As more providers of care were discovered, additional records were requested, including the records from Ms. Smith’s health insurance plan. Records from the plan offered additional background surrounding Ms. Smith’s activity during the 25 month period she was a patient of Dr. White. During this time, records revealed she also frequented numerous other care providers outside of the family practice group, seeking and obtaining prescriptions for controlled-substance medications. Pharmacy records from multiple chains demonstrated a pattern in which Ms. Smith rotated between various different locations every other week to fill prescriptions written by at least five prescribers. On more than one occasion, Ms. Smith had visits with multiple care providers on the same day, subsequently with new prescriptions being filled at different pharmacies. In these instances, Ms. Smith alternated between paying cash and submitting her pharmacy claim to her insurance for payment.

As this case progressed, and the records grew into the thousands, it became clear that the defense would benefit from a few demonstrative evidence pieces to help keep the facts straight, as well as highlight Ms. Smith’s “Dr. Shopping” and extraordinary ability to circumvent the system – receiving more controlled substance prescriptions than intended by any single provider. The ALN nurse analyst prepared a comprehensive pharmaceutical table of Ms. Smith’s prescription fills, which emphasized fill dates; pharmacy/location; provider; drug type, quantity, and class; corresponding office visits; and payment method used. The table was invaluable in assisting the defense team in piecing together the story of what transpired in the 25 months leading up to Ms. Smith’s death and analyzing the extent of her drug seeking behaviors. Secondly, the ALN nurse prepared a city-wide map, calling attention to Ms. Smith’s home address and the 17 pharmacy locations she utilized for her prescription fills during this time. The map was a powerful tool in helping visualize the efforts undertaken by the decedent to rotate her activities.

In the end, this case resolved with a modest settlement to the decedent’s family. The collaboration between the ALN consultants, defendants, and the legal team throughout the course of this case decidedly made a difference in the successful outcome. The ALN team’s ability to dig deep into the records and discern when further investigation was necessary helped uncover answers that positively altered the defense of this matter. Valuable lessons were learned by all in the process.