Is the solution to defensive medicine Recorded Calls or Documented Consults?

Joe Cantlupe for HealthLeaders Media asks “Can a Doctor’s Smartphone App Thwart Lawsuits?” and shares the founding story of Dr Michael Nusbaum, Chief of Bariatric Surgery at Morristown Medical Center, who has developed the MedXCom iPhone app in a bid to resolve the age old “who-said-what” problems that surround physician/patient discussions.

The story begins several years ago when Dr Nusbaum’s practice was involved in litigation from the family of a patient who claimed the practice was partially responsible for an untimely death due to a pulmonary embolism because they hadn’t been told how important it was to go to the emergency room. The article reports how the experience created a lot of tension in the practice which eventually led to the break up of the partners.

Being the target of this litigation pushed Dr Nusbaum to focus more on the practice of defensive medicine in a bid to prevent this happening again and moving forward he felt he had only two options 1) keep practicing defensive medicine (here’s a good overview of the challenges this approach can present by Dr Roy Benaroch) 2) Develop the MedXCom smartphone app to legally record conversations with patients so that he didn’t have to practice defensive medicine.

The app, known as MedXCom, is designed to record conversations and have them transcribed under a secured portal with HIPAA approval. In addition, the “patient’s whole medical history would be pushed into the smartphone, “Nusbaum says. The app is designated for physicians, but one is scheduled soon for patients as well, he adds. Users are prompted that the calls are being recorded… …Having a recording of the phone conversations helps make the doctor and patient more accountable,” he says. “We are trying to protect both ends, the patient and the doctor. It protects the patients by giving the doctor more and better information to make a good decision. On the doctor’s end, there’s protection. He can say, ‘Look, I told the patient to go to the emergency department and he didn’t go’… …In addition, if a physician fails to give a patient important information, the recording could confirm that, Nusbaum says. “If the doctor didn’t do [what he was supposed to do], the recording is there. Then you need to settle the case

It’s great to see yet another experienced Doctor innovating with mHealth technology but I’m not convinced voice recordings of consultations are going to deliver the benefits many might expect and I get the feeling the MedXCom service needs to be expanded a bit further before it can add sustainable value to patients and clinicians.

Here are my thoughts:

Recordings of consultations aren’t going to deliver the expected benefits

I can understand why some Doctors might look to the idea of making their own recordings of their calls after all patients are now using secretly made recordings against their Doctors and influential Doctors are positively encouraging patients to use their mobiles to make video/sound recordings of their Doctor encounters but in my opinion it runs the risk of letting defensive medicine win (as it could very easily begin to erode some of the important position of trust that exists when a patient consults with a registered Doctor) and may create a situation where you’re just patching the much more significant problem that exists with the vast majority of remote consultations (the taking of a thorough history is too time consuming and data intensive for a Doctor to take over a telephone).

I think playing to the idea that there is some sort of “medicolegal defence” race involving technology is also going to be counterintuitive as it will more than likely just inadvertently act to encourage patients to make secretive recordings. After all if the Doctor is getting a recording of the call why shouldn’t the person the call is being made for the benefit of be getting their own copy?

Once we go down this route we’re also going to get into a whole host of issues that will inevitably arise from the loss of such dispersed recordings eg. Doctors start recording calls so they can make more decisions over the telephone, a patient loses/disposes of their mobile and the info gets leaked online, someone claims the Doctor’s MedXCom service is insecure, patients lose confidence in sharing details with Doctors on telephones, with less info Doctors can make less fewer decisions over the telephone, etc.

As an anecdote I know a Doctor who discovered a patient trying to secretively make a recording of their in office consultation and she knew not because the tech failed the patient but because the patient behaved in a very unnatural way. Of course in that particular situation the discovery led to a much more open discussion taking place but we run the risk that this detection will be much more difficult to make when participants are remote (eg. you won’t necessarily see the patient as they shift nervously in their chair, it’ll be much more difficult to question the patient about recording equipment, etc) and it stands a good chance of negatively impacting the quality of the consultation if either party feels a need/pressure to perform for some uncertain future listener.

Documentation beats recordings

Even if we somehow had a perfect voice to text transcription service I think it’s obvious that the majority of us would be able to convey something more accurately if we had the opportunity to put it into writing. To make the point here’s a typical instruction a Doctor might think/tell/write/show a patient:

Doctor Thinks the patient knows what to do:

“Okay you’re having an anxiety attack” (thinks to self: everyone knows how to manage that right?)

Doctor Tells the patient what to do:

“Okay you’re having an anxiety attack so try breathing into a paper bag”

Doctor Documents what the patient should do:

“For help managing anxiety attacks check out this useful website

Doctor Shows the patient what to do:

“For the following reasons I believe you’ve experienced a panic attack; You described that you had been thinking about a traumatic life experience and that triggered the short term symptoms that are consistent with this diagnosis eg. palpitations, heavy sweating, nausea and dizziness. For help managing anxiety attacks check out this useful website and watch the following video:”

Making the move from Defensive to Documented Medicine

Although the MedXCom service boasts “All calls recorded for Medical/Legal purposes — No more, “The doctor never told me that” I don’t think in 2012 this is sufficient. If we’re recording things so Doctors can benefit from them (reduced medical defense risks) why aren’t we prepared to let patients get value from this too? If we’re ever going to create value and help patients work with Doctors to make decisions remotely we’ve got to start appreciating the limitations of voice calls even if they are supported by electronic medical records.

Also the act of making recordings can encourage Doctors to, intentionally or not, lead patients into taking responsibility eg. by reducing the lines of enquiry (eg. I won’t bother asking that because if i do then I’ll have to be seen to ask that and then I’ll have to rule out that x, y and z), changing the subject as soon as the patient says what we need them to say for medicolegal purposes and could have the overall effect of making all parties less comfortable about speaking the way they feel.

A third option

Another option that I think Dr Nusbaum should consider is the opportunity to let the patients “record” what’s wrong with them so Doctors can spend they have to consult with the patient focused on communicating with them and not on typing information into a computer) because most of the information shared is automatically documented.

Dr John Bachman, Prof of Primary Care at the Mayo Clinic, explains an effective way to use interactive patient history taking questionnaires to achieve this:

About David Doherty
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2 Responses to Is the solution to defensive medicine Recorded Calls or Documented Consults?

  1. Pingback: Is the solution to defensive medicine Recorded Calls or Documented Consults? | Digital Health Journal

  2. Pingback: BNetTV speaks with David Doherty from 3G Doctor at the mHealth Summit « mHealth Insight: the blog of 3G Doctor

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