Saturday, August 24, 2019

The Continuing Disaster of Electronic Medical Records

EMR's have been a disaster for clinicians.  As a patient, I like the patient portal, where I can get and receive messages, cancel appointments, get lab tests, etc.  But doctors are reduced to data input clerks, become much less efficient, and as some say, have their souls sucked out of them.  Here is a brilliant exposition:

 It is such a violation that the decision makers for purchasing these things, the government and the administrators, victimize the doctors by their own ignorance and lack of advocacy for the doctors, and for the entire system of medicine, if truth be told.

This has been known for some time, but there is no sign of improvement.  We're stuck.  Government is doing nothing.  Judith Faulkner, owner of Epic, remains a billionaire who obliviously observes, "Why would a patient want his medical record?"  And Epic then produces records that no one can really use well, neither patients nor doctors.  But they are good for billing!

Others say that doctors are just too stupid to use the EMRs correctly.  Right.

Medical care is becoming like the weather, everyone complains about it but no one does anything about it.  To me, the answer is strict government regulation of anti-trust measures, and vigorous pursuit of interoperative EMRs, regulating Epic and others as platforms, mandating that innovations from other companies be open for incorporation into them.

In medicine, corporatism is failing, as it has in so many other walks of life, because government has failed to regulate the marketplace so that competition is strong and works in favor of the consumer.

Just to make the feelings of doctors vivid, here are two trenchant comments from the American Academy of Pediatrics, Section on Administration and Practice Management Listserve:

Oh, man, he is singing my tune! (referring to the ZDog clip that started this post.)  I literally grew up with computers dating back to the Commodore 64 and Vic 20. I learned to program as an elementary and middle school child and was always very pro technology.  I was an early adopter of the palm pilot and handspring devices because they were innovating and creating new and more efficient ways to care for patients.  I used a Palm device to do my progress notes in residency and was able to do so efficiently. At that point, the technology increased my efficiency and organization, so I used it. 

I finished  residency and spent the first 11 years of my career on paper and was rather efficient. I saw roughly 6000 patients a year and then transitioned to electronic records. 

 After four years on Centricity, I can only see about 4000 patients a year while working longer hours.  Additionally, the quality of what I am doing for my patients is worse than what I was able to provide when I was on paper. Among other things, this is why I am finally setting out into independent practice.  At least I can choose my EHR this way. 

 All this to say that we could keep virtually every benefit of electronic records and regain quality and efficiency if we could return to paper for almost everything except a problem list, allergies and medications.  Perhaps in the hospital you might want to include a few other features, but undoubtedly you could make the system much more efficient and improve quality of care by eliminating most of what has to be done in the computer.  

My two cents,

DS, M.D.

I could not agree more.  While I did not grow up with computers, I was an early adopted of the Mac platform in 1986 when the 9” mac cost more than $3000 and had a 20 megabyte hard drive and floppy disc!  I used to love the Mac until, in recent years, it began to copy Microsoft in being packed with “features” that the average user did not comprehend or need.  It is still the best around, but getting harder and harder to use.

I too could see 6000-7000 patients yearly on paper.  Now, 4000 is a stretch and it is solely due to the adoption of the word vomit producing, time sucking, soul killing nearly useless EMR, also with much longer hours needed to be a click monkey.

The only useful part is ERx and allergies and legibility.  All other “improvements” in data collection, population health, and better care have been total vaporware.

Thank the government for essentially mandating the adoption of mutually incompatible, horrible programs for all, without any effort at producing a universal standard or insisting on user friendliness.

IMHO it has been a total disaster.  Longer hours, no eye contact, box checking instead of history taking, choices limited by databases, not by what you need and the total loss of ability of the clinician to find any useful nuggets of data amid the pages and pages of word vomit spewed forth by EMR.

And that was me being polite.

HL, M.D.

Saturday, August 10, 2019

Practice Liability When Treating Non-Vaccinating Patients

Reducing the Risk of Legal Liability To Third-Parties When Treating Non-vaccinating Patients

Budd N. Shenkin, MD, FAAPa, Dorit Rubinstein Reiss, PHDb, David I. Levine, JDb

Affiliations: a Bayside Medical Group, Berkeley, CA; and b University of California, Hastings College of the Law, San Francisco, CA

Abbreviations: American Academy of Pediatrics (AAP), Vaccine Information Statements (VIS), Non-Vaccinating Information Statements (NVIS)


Deciding whether to accept voluntary non-vaccinators into a practice has become increasingly controversial. One important concern is the fear that a practice accepting such patients might incur legal liability if another susceptible patient should contract a vaccine-preventable disease in the practice’s office. This paper addresses the question of legal liability and offers suggestions to minimize that risk.

Reducing the Risk of Legal Liability To Third-Parties When Treating Non-vaccinating Patients

As preventable disease outbreaks due to voluntary non-vaccination spread, deciding whether to accept these non-vaccinators into a practice has become increasingly controversial. Some authorities argue that it is ethically correct to care for children despite the risky decision of the parents, and many pediatricians want the opportunity to convince hesitant parents to vaccinate. Others, however, are vexed when patients reject medical advice, don't want the increased burden of treating non-vaccinated patients, believe that not accepting non-vaccinators is more effective than persuasion at increasing vaccination rates, and fear that they will be disserving other patients who cannot be vaccinated because of their age, compromised immunity, or other reasons.i In addition, some fear the possibility of their own legal liability if a susceptible patient should contract a vaccine-preventable disease in the office from a contagious, unvaccinated individual.ii This potential for liability has been noted by the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP).iii. Our concern in this paper is to address the question of legal liability and to offer suggestions to minimize that risk.

If Patient A were to contract a disease in a practice from voluntarily non-immunized Patient B, Patient A could sue the practice for negligence.iv The suit might allege: “Practice X knowingly included non-vaccinating patients who could potentially spread immunizable diseases to their other patients, but the practice neither informed all patients of that potential, nor took sufficient steps to reduce it.” Physicians have a special legal duty of care to avoid unreasonably harming others because of their professional knowledge and patients' reliance on their recommendations. Patients can expect that health facilities will be reasonably safe environments. In fact, hospitals (another natural congregating point for infectious disease vulnerable patients), have been sued over hospital-acquired infection.v Indeed, states seek to protect children against disease transmission by requiring vaccination for school admission.

If a preponderance of evidence proved that such a disease transmission took place in the practice's office, the practice's liability for monetary damages would hinge on whether the physician and the practice acted reasonably or negligently in safeguarding the injured patient’s health. The crucial issue would be, then, what actions are “reasonable?”

Courts would be unlikely to conclude that merely accepting such patients was legally unreasonable. This policy is still widespread and expert opinion is currently

The next issue would be vital: has the practice acted “reasonably” to protect patients from contagion due to unimmunized individuals? A trial court admits evidence of what informed opinion recommends in a field, such as AAP’s committee statements, to determine whether the defendant met the standard of care. Ultimately, a jury would have to weigh the evidence (presented through physicians testifying as experts) and determine what was reasonable under the circumstances.

Practically speaking, the plaintiff’s experts would have the complex task of proving that the disease was contracted at the practice’s premises and that the practice acted unreasonably. The litigation would involve lengthy investigation; early dismissal of the case would be unlikely because both inquiries are fact-dependent. The stakes for the practice could be high, if the insured’s liability limits were exceeded because of a very serious injury or if several children were injured in one outbreak. Even if the practice were not left financially harmed, the process could be harrowing for the defendants.

What Can A Practice Do?
For a practice accepting voluntarily non-vaccinating patients, it would be both medically ethical and legally prudent to take steps to safeguard the health of the other patients. These steps would help demonstrate that the non-vaccinator-accepting practice had acted reasonably should a legal claim arise. The safest way to avoid infecting other patients would be to treat unvaccinated children only with home and telehealth visits. Some practices might try this, but it would be impractical on a large scale.

A minimal step to would be to inform all patients that non-vaccinating patients are accepted in the practice. A simple notice in the waiting room might be insufficient to provide meaningful warning. We suggest instead that, similar to the Vaccine Information Statements (VIS) that are routinely used in offices, Non-Vaccinating Information Statements (NVIS) could be given to patients to be read and signed, and then kept on file. These would explain that the practice accepted non-vaccinators, and would detail the specific dangers of each disease, those most liable to contract the disease (babies, immune-compromised patients), and what protective measures the practice is taking. The weaknesses of any protection system should be noted, especially that many diseases are most communicable before there are signs of illness. Since a uniform NVIS does not currently exist, practices would need to develop their own, probably utilizing legal advice.

Another important measure would be to exclude potentially infected non-vaccinating patients from common spaces. The practice's computer system should inform staff that the patient involved is unvaccinated, especially at the stage of making the appointment, so that anticipatory protective steps might be taken. Since these patients might be infectious in a prodromal stage even when they are not known to be sick, the practice should consider if all visits should be accomplished by entering the office by a separate entrance, treating in an isolated room, disinfecting the room, and not using it for some hours afterwards. Certainly, these steps should be taken if the patient is symptomatic, as pediatricians did with suspicious infectious cases prior to the vaccines being available. Of course, if a case of infectious disease develops in the patient who has visited the office, all patients who might have been exposed must be contacted and prophylaxis offered, according to the directives of the Red Book.vii

A practice might also consider if state law permits requiring voluntarily non-vaccinating families to sign an indemnity statement accepting financial liability to the practice resulting from an outbreak emanating from them. (This indemnification would be in addition to a vaccine waiver, such as the one available through the AAP.)

Documentation that policies were actually being followed in the practice would be essential. As physicians have been told repeatedly, “if it is not documented, it did not happen.”

In summary, practices accepting voluntary non-vaccinators may be expected by law to act reasonably to protect all of their vulnerable patients from the foreseeable risk of disease transmission. Methods to avoid liability may be cumbersome, but practices accepting voluntary non-immunizing patients should consider adopting policies like those recommended here, for the safety of their patients and their legal protection.


iDeem MJ, Navin, MC, Lantos, JD. Considering whether the dismissal of vaccine-refusing families is fair to other clinicians. JAMA Pediatr. 2018; 172(6): 515-516.

ii Sugerman DE, Barskey AE, Delea MG, et al. Measles outbreak in a highly vaccinated population,

 San Diego, 2008: Role of the intentionally undervaccinated. Pediatrics. 2010; 125:747-755.

iii Rathore MH, Jackson MA. Committee on Infectious Diseases. Infection prevention and control in pediatric ambulatory settings. Pediatrics. 2017; 140(5):e20172857.
ivAmerican Law Institute. Restatement of the law third, torts, liability for physical and emotional harm. 2012.
vMiller JM. Liability relating to contracting infectious diseases in hospitals. J Leg Med. 2004; 25: 211-227.

viEdwards KM, Hackell JM, Committee on Infectious Diseases, Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016; 138(3): e20162146.

viiCommittee on Infectious Diseases, AAP, Red Book: 2018-2021 Report of the Committee on Infectious Diseases. 2018; 31st ed.