EMR and Deposition

 The day before yesterday attorneys deposed me for the first time since I started using an EMR (electronic medical record). I appeared as a fact (not expert) witness in a case involving litigation by a patient against another party. I had already provided extensive records to both plaintiff and defense attorneys, including faxes of my old paper records, copies of computer files on CD, and two different attempts at providing the patient's record from the EMR, at least one of which was almost certainly incomplete.

Because the EMR exists in the cloud I can access it from anywhere I have a browser and Internet connection. But since I do not "possess" the record I cannot comply with the usual subpoena that requires the witness to bring such an item to the deposition. Instead I faxed the attorney who apparently most wanted to depose me a letter informing him that I would need a browser and Internet connection in order to access the record during the deposition.

The attorney had me access the patient's electronic medical record prior to swearing me in. While all the attorneys looked over my shoulder I clicked through much of the record, attempting to print as much as possible of what appeared relevant. Satisfied and with multiple stacks of records in hand the attorneys proceeded to interrogate me.

Only one real problem surfaced: Attorneys can now automate printing of what used to be called Bates numbers on printed records, making it much easier to get everyone -- literally -- on the same page. Achieving this with a browser might require a different approach, such as sending the same image to a screen in front of each person.

Although everyone seemed happy with this solution I maintain that only through use of a browser can we access the complete record. Paper copies do not accurately represent the electronic medical record, if only because no electronic signature appears with each progress note. Also, I frequently save .mp3 files of voice mail messages to the record, and of course these cannot be printed on paper. Finally, relationships among different data sets cannot be represented accurately in a stack of paper copies.

I predict that someday the judicial system will have to adapt depositions and trials to allow for viewing such "exhibits" in real-time on a computer screen. Likewise, expert witnesses will require access to medical records via the Internet instead of attempting to understand the case by reading paper copies. For this to happen vendors of electronic medical software, especially cloud-based services, must provide temporary read-only access to a single patient's record. Currently my vendor does not have such capability.

Doctor Bites Medical Board

Not exactly, but if a man biting a dog qualifies as news, so must a physician successfully suing a medical licensing board, in this case the one I criticize best, the Washington State Medical Quality Assurance Commission or MQAC (That's right, M Quack.)

According to this news report in settlement of the case of Werschler et al v. State of Washington et al the State of Washington paid damages of $600,000 to a Spokane dermatologist for publicizing unsubstantiated charges against him while investigating an anonymous complaint which his now ex wife filed in the setting of a contentious divorce. The state also formally apologized.

Dr. Werschler's license credential page still displays documents related to a minor charge of failure to maintain a log of controlled substances in his office, but no indication of the bogus investigation -- or the apology:

https://fortress.wa.gov/doh/providercredentialsearch/ProviderDetail_1.aspx?CredentialIdnt=386799#

In my opinion Dr. Werschler demonstrated considerable restraint in settling for such a small amount given the impact on his practice. The revelation of such poorly executed, and presumably poorly supervised, investigation raises such serious doubts about the competence of MQAC that resignation of one or all board members might be needed to restore public faith in the organization.

At a minimum the state should add a document outlining the errors made and including an apology to Dr. Werschler's credentials page.

"Medical" Marijuana Users Need Not Apply

Only recently has "medical" marijuana begun to directly impact my psychiatric practice. When the drug was simply illegal I could deal with patients who admitted to using it just as I would if they admitted to using heroin or ecstasy. I could refer them for addiction treatment or maybe help them recognize how the drug might harm them, maybe even cause their psychiatric symptoms.

With the advent of physicians legally authorizing use of the drug as a treatment, however, I have struggled with how to approach new patients who believe that because a doctor recommended it they must need it. Were it any ordinary prescription drug I might consider whether to take over prescribing myself, or I might telephone the prescribing physician to coordinate treatment plans. But I suspect that physicians who authorize marijuana almost always do so indiscriminately with little regard for adverse effects, essentially circumventing the law in order to give these "patients" access to the drug for getting high, and I am not convinced the drug has any role in treating psychitric illness. In fact I suspect it would interfere with other treatments, or even worsen most psychiatric conditions. (Someday, just for kicks, I must try to call a marijuana doc and discuss the pros and cons of the drug for a particular patient.)

My choices of how to proceed:

• Pretend that the patient does not use the drug.
• Demand the patient stop using.
• Discharge the patient.
• Continue treating the patient, but regularly encourage them to give up the pot.

Recently another choice occurred to me: I can simply refuse to accept these patients into my practice even for an evaluation. This same approach has worked well for prospective patients who admit to wanting to continue benzodiazepines. Some time ago I made a decision to stop accepting these patients into my practice. Not only did I find the process of weaning them off to find out whether they still needed treatment of an anxiety disorder unsatisfying and troublesome, but it might discourage physicians from prescribing the drugs in the first place. I figure if physicians cannot assume that if something happens to them another physician will just pick up the ball, maybe they will try harder to find a different treatment.

Maybe if more of us refuse to accept "medical" marijuana patients we will discourage its use. Or patients will just lie about it. 

I hope this just represents another stop on the road to legalizing marijuana so doctors can get out of that loop altogether.

"Medical" Marijuana and Prescription Monitoring

Having run state prescription monitoring program reports on a few patients who report use of "medical" (Yes, I'm skeptical.) marijuana I wonder what should prevent the drug's inclusion. If the law requires pharmacies to report dispensing drugs from Schedules II-V, how hard could it be to require marijuana dispensaries to report this Schedule I drug? The same justification holds.

Physicians need to know what other physicians have prescribed, including marijuana. I certainly want that information about what my patients take, just as I want to know who prescribes what other controlled substances for them.

Marijuana should have a legal status similar to that of alcohol and tobacco, neither of which is scheduled despite the obvious danger and harm associated with them. Nobody talks about "medical tobacco." Leave us doctors out of it. But as long as doctors can authorize its use we should see it in monitoring reports along with oxycodone and alprazolam.

The more things change...

"Such was the view taken by the famous psychologist, Dr. William Erb, of the University of Heidelberg. He said "Nervousness (meaning nervous excitement, nervous weakness) the growing malady of the day, the physiological feature of the age. Hysteria, hypochondria and neurasthenia are increasing with fearful rapidity among both sexes. They begin in childhood, if not indeed inherited. Minds are overburdened in school, with too much teaching or misdirected teaching. The pleasures of social life follow, overexciting the already enfeebled nervous system. Business life is made up of hurry and worry and shocks and excitements. Society, science, business, art, literature, are all pervaded by a spirit of unrest, and by a competitive zeal which urges its victims on remorselessly. No man knows repose. The result is, wreckage. The pharmacopceia is overcrowded with nerve tonics, nerve stimulants, nerve sedatives. The medical profession devotes its best energies to the treatment of neuropaths. And as a people we are, or are becoming, excitable, irritable, morbid, prone to sudden collapse through snapping of the overtense chord of the nervous vitality." Nowhere are the rush and hurry and overstrain of life more marked than in this much-achieving Nation. The comparative youth and freshness and vigor of the American people enable them to do and to endure what would be beyond the power of an older and more worn-out community. Yet there is no disguising the fact that the pace tells even here, and often tells to kill. True, all the tendencies of the age are in that direction. Inventions, discoveries, achievements of science, all add to the sum of that which is to be learned, and widen the field in which there is work to be done. What we need to learn is, however, that all these things are for man, not man for them. If knowledge has increased, we should take more time for acquiring it, knowing that, with the consequent increase of power, we shall be able to achieve as much afterward in the shorter time as our Predecessors did in the longer time their briefer study afforded."

The People's Common Sense Medical Adviser 

1935

- R V Pierce, MD