Medscape Editor's Key Points:
Be sure to define your role in a "curbside consult" for the patient's sake and your own.
The electronic health record tracks everyone who accesses it—even just chart review—so be sure to look at the record only if you need to.
Accessing the record can transform you from outside observer to full participant in a patient's care.
If You Look at the Record, You're Involved
If there is a list somewhere of phrases that will spur disagreement among physicians, certainly "curbside consult" would be included. One case shows how easy access to electronic health records (EHRs) can affect how involved a physician will be perceived in a particular case.
A young mother was on hospital premises with her son, who was being treated for mast cell activation syndrome. The mother began to experience acute illness and self-injected two doses of epinephrine, which she carried because of her own history of anaphylaxis.
She was then evaluated in the hospital's emergency room, where she injected herself with a third dose of epinephrine. On evaluation, Dr. ED, the emergency department physician, noted the patient's history of recurrent unilateral vision loss and a tightening throat. Dr. ED's initial impression was that the patient's extreme agitation was not consistent with anaphylaxis.
Dr. ED contacted Dr. N, the neurologist on stroke call that day. Dr. ED and Dr. N discussed the patient's condition and at one point, Dr. ED asked Dr. N whether she should call a "code stroke" for the patient. Dr. N recommended instead that Dr. ED obtain a brain MRI, which Dr. ED ordered STAT. Dr. ED evaluated the patient again at 6:30 PM and noted that the patient was more altered, had bitten her tongue, and would need sedation for the upcoming MRI. Though the MRI was degraded by significant patient movement, the radiologist interpreted the study as negative for stroke. Dr. ED admitted the patient to the ICU at 9:30 PM.
The patient continued to deteriorate and required intubation overnight. A lumbar puncture and an EEG on the patient's second day were inconclusive and another brain MRI was undertaken on day 3. That scan revealed that the young woman had suffered an acute infarction of the pons and thalamus. As a result, the patient suffered "locked-in syndrome."
The patient and her husband sued the hospital and numerous physicians involved in her care over those first 3 days.
One issue of the multifaceted litigation was the extent of Dr. N's responsibility to the patient. Though he was the neurologist on call, Dr. N did not consider his discussion with Dr. ED as making him part of the patient's "care team," as he was not called in to see the patient and no stroke code was called prior to his call responsibilities ending at 7 PM.
Under these circumstances, a motion for summary judgment seeking Dr. N's dismissal from the suit would have had significant merit but for activity found in the patient's EHRs.
During the discovery phase of the litigation, the plaintiffs' attorney deposed individuals at the hospital with the most knowledge of the patient's medical records. That testimony identified Dr. N as logging in to the patient's EHR not only around the time of his telephone call with Dr. ED, but then again before midnight that evening. Those logs suggested access to the MRI and to the clinical notes, which by that time documented the patient's continued deterioration.
Though Dr. ED testified that at the time of her discussion with Dr. N she considered him a part of the patient's care team, there was no evidence that Dr. N took any further action or was involved with the patient, other than those EHR logs. With the plaintiff contending that excessive movement rendered the first MRI nondiagnostic, testimony pointing to Dr. N accessing the MRI would put him squarely in the middle of an argument that more should have been done for the patient that first evening.
Dr. N informally resolved the litigation with the plaintiffs, as did several other providers.
With EHR "metadata" able to show virtually every kind of activity involving a medical record, a physician accessing records while claiming no duty will be faced with a difficult question: If the individual is not a patient, what is the justification for reviewing that person's confidential medical chart?
And while the question of what constitutes a "curbside consult" may be forever debated, electronic proof of a physician's later review of the medical chart could very well knock the physician off the curb and into the traffic.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "Curbside Consults and EHR."
© 2019 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
Cite this: Gordon T. Ownby. Malpractice Case: When a Curbside Consult Becomes Patient Care - Medscape - Jul 05, 2019.