Making Hepatitis History Part 4: Time stamps can separate medical fact from fiction
In the first of my "Making Hepatitis History" series of posts, I wrote about the Southern Nevada Health District's Public Health Investigation Report about the Endoscopy Center of Southern Nevada, the epicenter of the worst hepatitis C outbreak ever to hit the US.
For an investigation that deals with dirty surgical instruments, you would expect an examination of sterilization logs. And for reporters now trying to sort out what happened, you can be sure that interesting records will turn up in bankruptcy court. But one of the smoking guns in the investigation was a something most reporters probably ignore: the lowly time stamp.
There were three types of time schedules that were integral to the investigation.
1. The staff schedule: where staff members were – or were supposed to be – throughout the day.
2. The room schedule: how the rooms in the surgery center were being used at any given time
3. The procedure schedule: how long procedures going on within the rooms lasted.
There were times recorded for each of these, usually in the individual patients' charts, either handwritten or with a time stamp.
When a patient or a whistleblower calls you with a sad story of something gone wrong at a medical center, ask for copies of the charts. If you can't get your hands on everything in the chart, because patient identifiers are involved, say that you would be happy with just the portions of the chart that document staff times, room times and procedure times with all the patient information blacked out. The truth is, even without knowing a patient's identity, you can often build a great story.
In the Las Vegas case, we already know that hepatitis ran amok at the center. The schedules help show that sloppy infection-control procedures were part of a much larger problem: an organization that was cutting corners, deceiving patients and possibly defrauding insurers.
Here are five ways to use schedules to find a story:
1. Define SOP (standard operating procedure). One of the recurring themes in the district's investigation is that what is written in the patients' charts does not match what staff members say really happened. For example, doctors usually did not visit patients right after a procedure, but staff members were told to make it appear in the charts as if the doctors did make those visits. "A former staff member reported that she was trained to record certain events in advance of the occurrence of the event. For example, the time a physician was at the patient's bedside was to be recorded before the patient left the procedure room, although staff reported that the physician did not typically visit the patient in the recovery area."
2. Compare notes. If you are interested in a particular doctor, for example, you can log their times in a spreadsheet to see if the charts make sense. If you find them performing three different surgeries within a 10 minute span, you either have a superhero on your hands or a fake. "A review of charts from the known days of transmission in 2007 identified that for 53% of patients, the physician was performing a different procedure at the time he was reported to have been at the patient's bedside, and the time at which the physician was present at the patient's bedside was consistently recorded on charts to have occurred seven minutes after the completion of the procedure."
3. Look for consistency. Some medical teams are well-oiled machines, but a team of physicians always showing up at a patient's bedside seven minutes after a procedure stretches the bounds of believability. In this case, the staff members were probably just trying to follow orders and were using seven minutes as a standard time lag. But there are other reasons times might be abnormally consistent. Here's one.
4. Find out what time is worth. We have all read about or reported on upcoding, where a hospital or doctor performs a cheap procedure but then bills for a more expensive one. The Endoscopy Center of Southern Nevada apparently was using the clock to help it squeeze a few more dollars out of every patient. "Staff members reported that anesthesia times were intentionally recorded incorrectly for the purposes of obtaining additional reimbursements. The staff members reported that the anesthesia times for procedures shorter than 30 minutes in length were typically recorded as 31 or more minutes." This is because anesthesia that went on longer than 30 minutes was billed at a higher rate. "A review of anesthesia times for procedures on July 25, 2007 and September 21, 2007 identified a total of 128 procedures for review. Of all procedures, 115 (90%) had reported anesthesia times of between 31 and 33 minutes, with a median of 32 minutes." Again, consistency is a clue here. A colonoscopy for someone with serious internal problems and one for someone who basically had a false alarm are not going to take the same amount of time.
5. Talk with the staff. The endoscopy center is closed. That means there are a lot of people out of work and probably angry. When one shop folds, find the other shops that compete in that area and ask the people heading into (or out of) the office whether anyone used to work at the center in the spotlight. Show the ex-employees the time stamps and schedules and ask them for their interpretation. Faking notes on the chart is nothing new. Remember Dr. Peter Breen at the University of California-Irvine? Breen has been accused by the California Medical Board and federal investigators of filling out patient charts before a procedure occurred. He called it "pre-documentation." Much of the facts in Breen's case came from a lawsuit filed by – you guessed it – a doctor who had been fired. The medical board amended the charges against Breen in December, adding new details.
Next week: Why the quiet guy in purchasing might know more than you think.