Patients can access healthcare from numerous sources these days: an urgent care center, a gynecologist’s office, an emergency room, or their own primary physician’s office. Not infrequently, a medical problem may require referral to ancillary facilities and to other practitioners. At issue is, who is responsible in ensuring that the needed diagnostic or treatment activities take plan in a coordinated way?
For example, a 35-year-old woman is admitted into an emergency room complaining of calf pain one week after an ankle sprain. The ER physician is concerned that the patient has a DVT (deep vein thrombosis) and orders a venous ultrasound. The ER physician then prescribes an oral antibiotic for superficial phlebitis and tells the patient to follow up with her family doctor. She does, however, she is seen by another physician covering for her primary doctor. He switches antibiotics. Subsequently, she is seen by her primary doctor who monitors the condition. Two months later, the patient develops a pulmonary embolism.
This patient did have a DVT. The standard of care is to treat this with fractionated heparin and warfarin by mouth at the moment the diagnosis is made. Starting anticoagulation early ought to prevent the complications, such as: pulmonary embolism, bleeding, or venous incompetence. This case illustrates the dangers that patients and doctors face when patients receive care from multiple services in our community. Proper care rests on timely and accurate communication. I believe a number of factors may have led to this series of deviations from the standard of care:
1. As recently as five years ago, a patient with a DVT would be admitted to hospital for treatment with intravenous heparin. In this age of managed care, patients receive treatment as outpatients whenever possible. This places more responsibility on primary care physicians and their ER counterparts to initiate care in a timely way.
2. Physicians that cover for other physicians in their offices may not receive ER or diagnostic reports in a timely way. This can lead to errors in treatment decisions or delays in initiating new treatment.
3. Some insurers require pre-authorization for expensive therapies, eg. fractionated heparin. A part-time physician may not know the proper procedures in obtaining permission within a managed care system. Delays in treatment or referral then occur.
4. Many outpatient offices are in the process of transitioning from paper-based charts to the electronic medical record. This transition phase is creating challenges. Most systems require labor intensive scanning of old documents in the EMR. Some practitioners must use a mixture of the paper chart and the EMR for a year or more while in transition. This may be a source of error for the practitioner as well.
In this case, the ER physician may have fallen below the standard of care by not initiating anticoagulation therapy. The primary physician covering for the patient’s doctor, likewise, may not have acted reasonably in the treatment of the patient’s DVT. Did either physician have timely access to the results of the venous ultrasound?
In summary, the primary care practitioner must operate an efficient and organized office that keeps on top of the flow of medical data to and from his office. As we all transition to the EMR, the primary care doctor and his staff will be under increased pressure to work effectively. Even though we are under constraints to treat and diagnose our patients as outpatients, good medical practice requires that patients’ problems be dealt with according to appropriate standards of care.
I look forward to dealing with the legal community in sorting through patient care issues that arise as patients receive care in a variety of settings in our community.
Dr. Howard Sawyer is board certified by the American Board of Family Medicine. He is experienced in issues involving nursing home care, delay in diagnosis, misdiagnosis, failure to diagnose, failure to treat, diabetes, orthopedics, pediatrics, fractures, hypertension, coronary disease, cancer, osteoporosis, stroke, heart attack, prostate and lung disease. He has been offering his expertise as a medical expert for 15 years. He remains in full time primary care practice and supervises the outpatient work of a number of internists and family physicians. Dr. Sawyer can be reached by phone at (818) 781-7097 Ext. 3232.
