Get a handle on electronic hospital data: hospital patient data can reside in a simple database or in a fully integrated electronic system. Both may contain more information than meets the eye.

Although nearly all hospitals manage data electronically, few have fully accessible and integrated electronic data systems. The transition from paper to electronic hospital records has been staggeringly slow, due to cost as well as the resistance of doctors and staff to training.

It is surprising that more hospitals have not jumped on the technology bandwagon, considering how much an integrated system can improve efficiency, communication, and patient care. It seems that the marketplace, more than government agencies or standards organizations, is the driving force behind the steady but slow transition to electronic records. Nevertheless, organizations such as the Joint Commission on Accreditation of Healthcare Organizations have begun to acknowledge the emergence of electronic records in their publications.

Typically, each department in a hospital maintains its own electronic information system to keep and analyze data. The system may work well for that department, but it usually is not integrated with the rest of the hospital's information flow. No matter how good the individual department's system is, the data must be printed out and placed in a paper chart if health care providers in other departments need to see it.

Such disjointed record-keeping is slowly being replaced by integrated electronic medical records systems. These systems bring all aspects of patient record-keeping into a computerized chart that is accessible from any workstation in the hospital, provided the user has the appropriate security clearance. This way, all health care providers have ready access to all the patient's information, regardless of where the patient's chart is.

Electronic databases may contain more details than paper records, such as greater detail in diagnoses and disposition data. Careful review of both electronic and paper records can reveal information important to litigation. In some of my cases, the description of the patient's presenting symptoms in the electronic database has differed from the description that finds its way to the chart.

An attorney representing a plaintiff in a medical negligence case must have a working understanding of the most common types of electronic hospital data. A variety of data is created for a patient during a hospital stay, and you should know where to find the basic information as well as any underlying data that exists. Whether the information you need is stored in individual departments or an integrated system, you must be able to identify it so you can properly retrieve it for case preparation.

Discovering databases

Scheduling. Many hospitals maintain not just a database of patient information, but also a list of appointments made, canceled, and changed. This most fundamental data may never appear in the chart but can be important in a case, especially where a question arises about whether a patient kept his or her medical appointments.

Fully integrated scheduling systems allow staff to plan diagnostic tests more efficiently, with less need for return or duplicative appointments. This benefits both hospitals and patients.

Department logs. Hospital departments often keep electronic logs that never become part of a patient's chart. For example, operating rooms maintain surgical record databases that contain information such as the type of surgery, the health care providers involved, and the location of the surgery.

Emergency rooms typically maintain databases that keep track of when a patient enters and departs the emergency room, what testing is conducted, and what the outcome is. All emergency rooms have at least a simple staffing log--paper or electronic--that shows how many and what type of staff are available for any given shift.

Discovery of the data underlying a department database often reveals essential information. For example, when the issue is whether the emergency room was overwhelmed by the number of cases on a certain day, the logs will clearly show which patients were in the emergency room at any given time. When the issue is how many laparoscopic cholecystectomies a defendant physician has performed, the operating database may show the exact number.

Diagnostic data. All hospitals use ICD-9 codes to designate the diagnosis of a patient on discharge. The hospital maintains this data for various purposes, including tracking the nature and extent of hospital-acquired infections, postsurgical complications, and prevalence of different types of surgical procedures. ICD-9 codes are specific and detailed, and they provide a wealth of statistical information. By searching ICD-9 data, you can determine the hospital's incidence of postoperative infection, the rate of perinatal asphyxia, the number of vaginal births after cesarean (VBACs), and any other information that relates to specific diagnoses.

Narrative notes and dictation logs. Some new hospital systems and doctors' offices provide for all narrative notes to be entered into the system electronically. This method does away with legibility concerns and provides a more permanent record, because the data is transmitted from any workstation into a central system rather than simply entered into a paper chart that can be misread or misplaced. Graphic A is a printout showing narrative notes that were added to a patient's chart electronically.

When a hospital receives a request for records in litigation, it may not print all the data--due to oversight or some other reason. In one case, for example, I was certain that additional nursing notes existed, but despite a request for production, the hospital did not release them. Only when a particular physician from the hospital was deposed did it become clear what records were missing and how they could be retrieved. The records department apparently didn't know How to access all the electronic data. This type of problem may persist while the health care industry is converting from old paper records to new data systems.

Many cases involve questions about dictated notes: When were they recorded? Were there multiple drafts? When was a note entered on the chart? Most hospital dictation systems are electronic and provide a unique number identifier for each person dictating. That number can be coordinated with the patient's identification number to track every dictation the health care provider made for that patient. A typical log shows the date and time the dictation was entered, and it may show how many drafts were generated and any changes that were made.

Radiology. Almost all imaging studies either are generated electronically or can be converted into electronic format. It is now common practice for a radiologist hundreds of miles away to review a film or study over the Internet.

Check to see if the hospital has maintained the original data from the CT scan or MRI study. Some hospitals retain this data permanently. The original images are the best ones for experts to evaluate.

Often, CT and MRI studies can be produced on a disc that an expert can view later. In fact, many hospitals now prefer to produce discs rather than films. In my cases, several hospitals have provided discs with an electronic copy of all a patient's imaging studies for a minimal charge, yet they charge $25 to $40 per film for printouts.

In addition to the images themselves, the radiology department may have other relevant data, including requisition forms (which may contain crucial information on the ordering physician's reasoning for the order); logs showing the date and time of a test, indications that the ordering physician recorded, or identification of the technician; and data that shows exactly when a study was done, when the radiologist read it, and when the report was transmitted to the ordering physician.

Cardiology. In a typical medical record, cardiology studies are represented by some kind of report, such as an EKG page or an echocardiogram report. However, the actual data underlying the report often is available for the asking. EKG machines maintain data on your client and any other patients who were tested at the same time. Many hospitals keep this data indefinitely. In one case, I was able to prove that a cardiology department misread some EKGs as a result of confusion about which EKG corresponded to which patient.

Echocardiography data has changed rapidly. Videotapes of echocardiograms have been available for years, but most modern echocardiography machines can also produce digital copies of the video on CD or DVD, along with underlying data that shows the machine settings.

Anesthesiology. Anesthesiology departments were among the first to incorporate technology in both monitoring and record-keeping. Many now use automated record-keeping systems, which replace the old graphical anesthesia record with a fully integrated digital printout that contains all the information you would normally expect in an anesthesia record.

For example, it may include a table showing which anesthetic agents were used or a graph (as shown in Graphic B) showing blood pressure (Artsys, Artm, and Artdia), heart rate (HR), oxygen saturation (O2SAT), and end tidal carbon dioxide levels (EtCO2, which is a strong indication of the efficiency of oxygen exchange in the lungs) during the period in which the patient was anesthetized.

This data usually is dependent on some type of human input but also may include automatically generated information.

The anesthesia machines themselves can be a source of valuable data. Most machines have a memory feature that stores information--such as the nature of the anesthesia medication being injected and the patient's pulse, blood pressure, pulse oximetry, and oxygen flow--in real time, as it was recorded. You can compare a printout from the machine (see Graphic C) with the hand-prepared paper anesthesia record to check for accuracy.

Graphing data. At the end of a hospital stay, the patient's medical record usually includes a printed list of all the laboratory studies that were conducted. However, in a true electronic system, the health care provider has many more options for viewing this data. For example, one lab test for a patient, such as glucose, can be isolated and graphed over a 10-day period to reveal trends. A physician can also configure the program to show only abnormal test results.

Sometimes, the timing of a laboratory order or test can be critical. Most electronic systems contain data that shows when a test was ordered and performed.

Other traditionally graph-based records often can be found in electronic form. The newest electronic fetal monitors now provide for electronic data entry by health care providers, detailing examinations, blood pressure, and other clinical findings, as well as a precise digital graph of fetal heart tones and uterine contractions.

Moving toward integrated records

Hospitals are slowly converting to completely integrated electronic medical records. These systems' database functions allow all health care providers to view the patient's complete chart from any network terminal, granting immediate access to laboratory reports, imaging studies, and other diagnostic tests. Powerful software tracks treatment protocols programmed for a particular patient, and it may even suggest alternative tests and treatments.

Most systems also contain a modification log that tracks every change made to any document since its creation, including the date, time, user name, and the change. Some of these systems have succeeded in reducing errors in all aspects of health care, including medication administration, team coordination, and diagnosis.

In a case involving the discovery or evaluation of electronic hospital data--whether limited to one department or part of a truly integrated electronic records system--you should consider hiring an expert consultant to navigate these previously unknown waters. A Rule 30(b) (6) deposition, in which a person designated by the hospital testifies about the nature and extent of its system, can be an extremely useful tool. In fact, such a deposition might provide the foundation for all further discovery from the hospital.

When formulating discovery requests to medical institutions, you must be ever mindful of the manner in which the health care that a client receives involves machines and systems that may include electronic data. Anytime a machine is used for a patient's care, and that aspect of care is important to the claim of negligence, you should make specific discovery requests to retrieve that data.

For example, in any case involving an anesthesia mishap, you should request "all data, including printouts of such data, produced by the anesthesia delivery machine used for plaintiff's surgery, including but not limited to the measurement of blood pressure, end-tidal C[O.sub.2], pulse, [O.sub.2] saturation, and flow and type of anesthetic agent."

Every hospital system is different, and almost all use electronic data that is unfamiliar to even the most experienced practitioner. As more hospitals move toward pure electronic records, lawyers will need to stay ahead of the curve to properly represent clients.

JAMES P. FRICKLETON practices law in Leawood, Kansas.