A patient alleged that physicians at the Central Maine Medical Center had information about his increased risk for prostate cancer for nearly 4 years without telling him or taking action.
The patient was diagnosed with prostate cancer in 2020.
A settlement was reached last week.
Micheal Whittier of Poland, ME, alleged that doctors at the Central Maine Medical Center (CMMC) had test results demonstrating his high risk of prostate cancer in 2016, but that they failed to inform him or order any follow-up testing. A malpractice suit filed by Whittier and his wife claimed that his enlarged prostate was first noted by a physician at CMMC’s Mechanic Falls clinic in 2016. Lab work showed highly elevated PSA levels. These results were reportedly sent to CMMC in January 2016. CMMC did not inform Whittier of the results, and there were no consultations or follow-up tests ordered.
Whittier returned to CMMC just over a year later for an annual exam. Although his medical records contained his PSA test results, information regarding his enlarged prostate, and notes about the need for further evaluation and a consultation with a urologist, no action was taken during this 2017 exam. Whitter was still not informed of his test results, and there were no tests or consultations ordered.
CMMC’s Mechanic Falls clinic closed in 2017. From 2018 to 2020, Whitter was seen by physicians at CMMC’s Auburn clinic. According to records, he was seen three times in 2018, twice in 2019, and once in 2020, all without any mention of or action taken regarding his PSA test results.
In May 2020, Whittier saw a new CMMC physician. The new physician noted that a previous, out-of-state physician had notified him of Whittier’s PSA test results. The new CMMC physician ordered a urology consultation. A urologist evaluated Whittier and ordered a prostate biopsy. The biopsy came back positive for prostate cancer.
In November 2021, Whittier underwent prostatectomy surgery, but the cancer had already spread beyond the prostate. He then began treatments with radiation and Lupron injections. The malpractice complaint alleged that by not informing Whittier earlier and by failing to follow up on his test results, physicians at CMMC allowed the prostate cancer to grow too large to be cured by a prostatectomy.
CMMC upgraded its electrical records system in this same time window. The malpractice complaint alleged that CMMC negligently failed to import certain laboratory results into the test results dashboard of the new system and that Whittier’s 2016 PSA test result was not imported. The suit alleged that CMMC had a duty to:
“[R]eview and understand Whittier’s medical history and testing results; to accurately document his medical history; to correlate his medical history with his clinical presentation, including ongoing enlarged prostate; to manage its electronic medical records to accurately record, track and report test medical information including test results, and to communicate the medical history to Whittier and other providers who needed this information.”
The case went to trial on September 25, 2023, in Maine’s Androscoggin County Superior Court. Jurors heard several days of testimony on charges of medical malpractice, continuing negligent treatment, fraudulent concealment, and Nancy Whittier’s loss of companionship, comfort, and care. A settlement between the Whittiers and CMMC was reached on October 1, 2023. The settlement amount has not been disclosed, but Whittier’s attorney, Ben Gideon, stated that his clients were satisfied with the outcome and felt they had accomplished their goal.
Electronic medical records and medical malpractice
The use of electronic medical records has become increasingly common; it has also become an increasingly common element in medical malpractice cases. This can be due to problems with data transfer; issues with the way electronic health record (EHR) screens and systems are set up; fragmented records being transferred from facility to facility or from paper to electronic form; a lack of compatibility between facility systems; and user error. For instance, many EHR systems are set up to auto-populate previous data or rely on drop-down menus to fill in certain boxes. These functions can lead to outdated or incorrect patient information being input repeatedly.
Chad Anguilm, Vice President of Growth at Medical Advantage (part of TDC Group), suggests that physicians always take the time to verify any information in EHR records and documents to avoid possible errors.
“It’s important not to blindly trust all outside inputs. Physicians need to ensure they understand where system inputs originated and be sure to verify they are accurate with the patient and/or caregiver. By reviewing medical history, problem lists, past surgeries, allergies, and hospitalizations, physicians are able to validate system-generated medical history with the patient or caregiver,” Anguilm says. He adds that reviewing the visit with the patient and giving them access to a visit summary can help ensure information is communicated.
“A quick, verbal review at the end of the office or phone visit can go a long way to ensure everyone is on the same page,” he explains. “Immediately following the visit, a summary can be generated from the electronic health record and either printed or uploaded to the patient portal. This further ensures [that] all parties understand what took place during the visit, what was documented and, lastly, what the treatment plan is going forward.”