Electronic health records (EHRs) have the potential to greatly improve health care. They can provide clinicians with a central location for information and a complete medical history of a patient, including facts that an individual might forget to mention. But what happens when a misdiagnosis becomes part of a patient’s EHR? Does it change the thinking or the actions of the subsequent treating clinicians?
Ms. P was a physician assistant with a large HMO. She’d held the position for the past five years and was eager to find a new job. Although she liked the variety of work, she detested the corporate policies that the HMO imposed on herself and her colleagues.
Administrators at the HMO stressed the importance of speed during examinations and the need to get patients in and out of the clinic quickly. Clinicians were warned not to order “unnecessary” tests and to refer patients to specialists within the HMO whenever possible — if a specialist was really necessary.
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Administrators kept track of how many patients each clinician saw per day, and Ms. P often felt pressured to rush. She wasn’t the only one who felt this way: Many of the physicians and other practitioners would complain that they sometimes felt they were performing factory work rather than medicine.
One afternoon, Mr. N came in complaining of “gray outs,” or intermittent blindness in his right eye. He had no history of serious ailments or chronic conditions and was in good health for his age; Mr. N exercised regularly and did not smoke or drink to excess. As Ms. P examined him, Mr. N chatted about his job as a middle-school teacher and his two young daughters. Ms. P was polite but could not spend time on small talk and conducted the exam quickly and efficiently.
“I’m referring you to an ophthalmologist,” Ms. P told the patient as she typed notes into the EHR system used by the HMO.
One week later, Mr. N returned, this time with his wife, who was less mild-mannered than her husband.
“The ophthalmologist said there was nothing wrong with his eye,” said Mrs. N. “Yet he’s still having these periods where he only sees gray. Plus, he’s having headaches and neck pain. I insist you refer him to a neurologist.”
Ms. P was not fond of overbearing spouses but conceded that Mrs. N had a point. The ophthalmologist had found no structural issues with the eye, so Ms. P referred the patient to one of the HMO’s neurologists.
Several weeks later, Mr. and Mrs. N returned. Ms. P looked up the patient’s EHR and noted that the neurologist had diagnosed retinal migraine. Ms. P explained the diagnosis to the patient and his wife, but Mrs. N wanted more immediate attention.
“The neurologist rushed us,” she told Ms. P. “He hardly spent any time at all with my husband, and he ignored my concerns. I told him that I think my husband should have an MRI. His symptoms haven’t gone away. And now his left pinky is tingling. The neurologist ordered an MRI but scheduled it for two months from now.”
Ms. P checked the record and saw that Mrs. N was correct. She told Mr. and Mrs. N that she sympathized, but there was already an order in for the MRI, so they should just wait.
The unsatisfied couple returned one week later during a time when Ms. P was not on duty. They were seen by one of the HMO’s physicians, who consulted the EHR, noted the diagnosis by the neurologist, and reiterated precisely what Ms. P told them earlier.
The next week, Mr. N experienced total blindness in his right eye. His wife took him to the HMO’s urgent-care clinic. A physician told him he was experiencing a retinal migraine but agreed to run a CT scan to placate Mrs. N, who was loudly insisting that something was wrong. While waiting for the CT results, Mr. N suffered a devastating stroke. Emergency department clinicians later diagnosed a carotid dissection as the cause.
Mr. N lost the use of his left arm and suffered left-side weakness. He also sustained permanent cognitive and mental deficits as a result of the stroke, as well as the amputation of both legs. Mrs. N was told that her husband would need full-time care for the rest of his life. He would never be able to return to work or lead a normal life.
Ms. P was unaware of Mr. N’s resulting stroke until an administrator informed her that the HMO was being sued by Mr. N and his wife. Ms. P learned that she and several other clinicians would be called on to testify at the arbitration hearing. The panel ultimately decided in favor of Mr. N and awarded him $5 million.
Legal theory
This HMO required its members to have their cases settled by arbitration rather than traditional court proceedings. Often only one arbitrator decides a case; however, because the amount of money being sought in this case was significant, the respective parties put together a three-member arbitration panel. It consisted of a neutral arbitrator and two additional arbitrators—one chosen by each side. The benefit to arbitration is that it usually saves time. In addition, the costs involved in trying the case are often less than in civil court.
Protecting yourself
Unfortunately, Mr. N’s EHR may have played a role in preventing him from getting the care he needed. The neurologist’s incorrect assessment followed Mr. N from clinician to clinician. Each looked at the EHR and assumed that the diagnosis was correct and made no further effort to determine the cause of Mr. N’s intermittent blindness. Had any one of the attending clinicians looked at the composite picture — headaches, neck pain, tingling sensation in the finger, and trouble seeing — they would have had a clear signal that Mr. N was experiencing more than just a retinal migraine.
What Mr. N was suffering from when he first went to the HMO were transient ischemic attacks of the retina caused by intermittent disruption of blood flow to the eye. In men younger than age 60 years, such as Mr. N, the most common cause is carotid dissection, which is diagnosed with an MRI of the head and neck. Had the MRI been performed early, Mr. N could have been treated with anticoagulation drugs that would have prevented the stroke, and the carotid dissection would likely have repaired itself within six months.
Just because a clinician has made a diagnosis does not mean that it should be accepted without question — especially if the patient’s problems are not resolving. Had Ms. P or one of the other clinicians questioned the initial diagnosis, Mr. N might have received the treatment that he needed in time.
