Save Your Money and Help Your Physician Expert

When I consider taking a case as an expert witness, I always ask how many pages of records the law firm needs me to review. If the answer is a large number, I am sometimes told “but don’t worry, we have a summary that has already been made”. I am left to wonder if the firms were going to pay that employee or company to summarize the records for themselves anyway and if they feel that such a summary would actually help me. I have also been solicited by companies that offer this service and the salesperson always paints the picture that their “timeline service” will help me so much that the hefty price tag is well worth it. I could not disagree more. If attorneys, themselves, need such an outline, I am all for it. Whether such a third-party medical summary is helpful to your physician expert witness, completely depends on the expert you have hired for your case.

Two Types of Physicians:

There are two types of attending physicians: those who know their work is more precise than the work of residents, nurse practitioners or physician assistants who are working under them and those who assume the work of these assistants is accurate, take a more hands-off approach and delegate more responsibility to them in order to see (and bill for) more patients. For the first type of physician, assistants slow them down. For the second type of physician, these assistants speed them up and often do much of the work. 

The first type of physician is more concerned with liability and precision. The second type of physician places higher priority on speed and volume of patients seen. One may certainly argue that the “sweet spot” is in the middle and there is no denying that pressure placed on us by insurance companies and administrators are the driving force behind the “need for speed” when it comes to patient care. 

Keep these two categories of physicians in mind if you have a medical malpractice case or a personal injury case in which you pay a physician expert witness to review the medical records then offer them a summary written by someone else.   Are you willing to put a physician on the stand who heavily relied on a nurse’s timeline for your case in order to “review” the records more quickly? Do you feel pressure to pick and choose which records the physician reviews in order to stay within the budget for your case? How contentious are the fine points of your case and to what level of detail does the physician need to document these in their report? 

I spent four years in medical school, four years in residency, two years in fellowship and several years as a faculty attending physician honing my skills in a niche area of clinical focus. No nurse or other assistant with less than equivalent credentials and a passion for my area of medicine would be able to glean the same level of relevant detail in a summary of records. Neither would they be able to put together the “big picture” of the case from thousands of pages of records like I can. This is because of the old adage “you don’t know what you don’t know” and I would make the same sort of mistakes if I were asked to summarize thousands of pages of records for the eyes of another professional who was highly trained in a niche field of some other profession. Furthermore, there is a huge variation of knowledge in nurses who practice in different settings seeing different types of patients (neonatal vs geriatric) and different areas of medicine (ICU vs rehabilitation). Last, but not least, I believe that what is missing in the medical record often speaks volumes more than what is actually documented there. In other words, if fine details should have been asked and documented by the medical team due to the patient’s diagnosis, if certain parameters should have been followed but weren’t or if there were tiny red flags that should have been caught and pursued but nobody documented them in the medical record, there is no way on earth that a nurse or company specializing in medical record summaries is going to pick up on this. If you have a high-stakes case, it is like forensic accounting. You may not want to pay the administrative assistant at the accountant’s office down the street to “summarize” your money-trail for you.

Hence, these third-party timelines are pretty useless to me. 

I, personally, glance at them only to make sure my dates and names are the same on the timeline that I create for my report.  However, if you have hired a physician in the second category mentioned above, he or she may thank you lavishly for a nurse’s summary. 

What is far more helpful is to organize the medical files so the physician can navigate them intuitively and quickly. You can also prepare the PDFs in such a way that drastically saves time when the physician is pulling information from them for their notes and report. 

Processing Medical PDF Files Like A Pro:

First, I recommend going paperless until it’s time for referencing documents quickly in a deposition. Paper files will likely produce paper notes by the physicians (think highlights, and sticky notes). These are discoverable and who needs that hassle?

Second, understand that most PDF files (particularly those created by scanning a document) cannot be searched electronically nor can one make digital highlights on them. Making PDF files electronically searchable not only helps expert witnesses, it also helps your firm any time that you need to quickly search thousands of pages of PDF files for a name or phrase. Electronically searchable PDF files also improve the quality of the expert’s report due to ease of referencing specific lines of text in the record. How do you make PDF files electronically searchable? Process them with OCR (Optical Character Recognition). However, be aware that doing this on PDF reader software takes an incredible amount of time so do it prior to sending them to the expert witness so you don’t spend their hourly rate on something that a secretary can do. Major PDF reader software (like Adobe) can do this, however Wondershare’s “PDFelement” is a much cheaper alternative without monthly subscription fees. The process requires a simple push of a button then “forgetting” about it for an hour or so until finished. It can run as a background process while staff work on other things. Some large all-in-one copier/scanners may run OCR and do it faster. One of my clients mentioned that a medical record service that they use will run OCR upon uploading documents to them. Whatever method you choose, you will be happy about the time you save by being able to search through a mountain of case files. I am also a fan of OCR-processed PDF files because I like extracting my PDF highlights and importing them directly into the draft of my report. I get some biting detail in my reports that way and it saves my clients a lot of time on my billable hours. Does your expert do this? You may want to ask your expert if they leverage this technology and skip OCR-processing if they don’t but I think it may improve the way you, the attorney, read files for cases in the future.

Organizing the Medical Files Like A Pro:

Better Bates Are Good for Everyone:

Next comes the task of organizing the files in a way that makes the most sense to a physician. If you are representing the defense in a case, there is a good chance that you were sent 10,000 pages that were so disorganized they could have been tossed into the air prior to being stamped with Bates numbers. Do not cripple your expert by confining them to this mayhem. Leave those useless Bates numbers on the bottom right but ask your office staff to rearrange the document as I describe below. They can do this easily in any major PDF reader via “dragging and dropping” the pages in “thumbnail view” and then adding “bookmarks” to them.

Once the chaotic pages are organized logically, you can always add a second set of Bates numbers in another corner with nomenclature that is clearly distinct. For example, you could configure them to start with the letters of your law firm followed by numbers. While drafting their report, the physician can utilize the sane set of new Bates numbers to efficiently navigate the medical records and save on billable hours. When finalizing the report, the physician can make sure to include the original Bates numbers which will also be utilized by opposing counsel during the deposition when questioning the physician.  Let them deal with their own messy Bates numbers. Meanwhile, your expert has his ducks in a row with both sets. As long as you use clear nomenclature in separate corners, nobody is going to get confused. 

If you represent the plaintiff, you may be the first side to label the files with Bates numbers. Please don’t stamp the files before they are well organized. Thousands of disorganized pages that are stamped with Bates numbers don’t help either side. Justice can only be served when both sides navigate all the data and present opinions based accordingly, not opinions based on a cat-and-mouse game of finding hidden bits of information.

One of my clients said that he was afraid of rearranging the medical records because it would appear his firm was tampering with the record somehow. They felt there was value in delivering the pile of medical records to the expert “just like the other physician would have seen the records”. Let me dispel that notion. In 2020, the overwhelming majority of physicians use electronic medical record systems. This means that they access records via computer interface. You will never “see” a medical record “just like the physician would see it” once it is printed on paper. That is akin to thinking that printing all the contents of LexisNexis allows one to see documents just like an attorney sees them there. Even if a clinic is still using a paper chart in 2020, those charts are compartmentalized and may contain records that were not discoverable in your case. When your discovery request hits the desk of the office manager, some office worker will be delegated the task of dissembling the chart and choosing which documents are copied. Furthermore, the order in which they are copied and stacked together again will be completely random. Even if you had the very same chart in your hand that the physician used, you would never know exactly what he saw and when he saw it unless he took the time to specifically reference sources in his notes.

Please help everyone involved in the case by putting chaotic medical records in some sane order. There is nothing biased in this. It is a “win-win” and well worth the staff time of office staff whose hourly rate is less than your expert’s.    

What To Group Together and In What Order:

Outpatient Clinic Notes

1.    Group and digitally bookmark all clinic visit notes according to the name of the clinic. For example, “North Dallas Family Medicine Clinic” or “Children’s Hospital Neurology Clinic”.  Sometimes it makes sense to do this according to the physician’s name (if the clinic is owned by the physician and carries his name) but at major medical centers, the patients may see multiple different doctors or “physician extenders” every time they go to the clinic. If the clinic name is something other than the name of the physician owner, use the name of the clinic instead. You may then add the name of the supervising physician to a digital bookmark on your OCR-processed PDF.

2.    Within the clinic stack, put the visit notes and all other notes in chronological order. If possible, highlight the date of each major visit note or bookmark by date. It will help your own firm’s attorney quickly reference files during depositions.   

3.    If there are copies of outside medical records from other places in the clinic file, separate them and put them all together at the very end. These records are often duplicates and your expert needs to review them in the source file primarily. These outside records will have original fax dates on them and they won’t be in any certain order when you receive them from the doctor’s office so don’t waste time trying to keep them in any certain order.  

4.    You may see notes named “nurse’s notes”, “call notes”, “physician’s orders” or even “scheduler’s notes” within a clinic file. Slide them in chronological order between the doctor’s appointment notes. That makes it clearer what communication was going on between each visit with the doctor and clinic staff.  

ER Visits NOT Associated with a True Admission into the Hospital

These are also called “23-hour observation” stays.  These are so short that it’s not essential to spend much time arranging them. However, the “Triage” papers should go first and the “Discharge Instructions”/any other discharge paperwork should go last.

Therapy Notes

1.    If these have been sent to you directly from one therapy center, great! If lots of notes from lots of places have been sent to you in aggregate, separate them according to the therapy company (ex a home health agency) or therapy center. 

2.    Next - Group all Physical Therapy Notes together. Group all of the Occupational Therapy notes together and all of the Speech Therapy notes together. 

3.    If you want to be really helpful, highlight the date and put in chronological order.

Outpatient Radiology Studies

1.    Group first according to the radiology center name.

2.    If there are many studies that were done there, then highlight the dates of the radiology reports and put them in chronological order. 

Hospital Stay Notes

    Just because records have the name of a hospital on them, doesn’t mean that the patient was there for a hospital “stay”. Sometimes a patient just goes to the ER. Sometimes they stay on the premises for up to 23 hours without it being counted as a hospital “stay”. These are called “23-Hour Observations” and they should stand on their own. Do not lump them with a true hospital stay but patients usually do enter the hospital via the emergency room and the notes these ER notes do need to be lumped with the hospital stay.

    If you request records from a hospital and the patient has only been there once, great! On the other hand, if they have been there multiple times, and have visited the radiology department or a hospital clinics between stays, it may not be obvious what papers go together because all of them will have different ranges. Furthermore, putting all the pages in chronological order is a complete waste of time and salary of office staff. This is how I would streamline it:

     If you have OCR processed the file, do a search for “Discharge Summary”. When you find that document, it will tell you the admission date and discharge date for that stay. By the way, while you are here, highlight “Discharge Summary” and bookmark that page. The attorney working the case will love that because this is the most helpful document of the entire thousand-page hospital stay. Now that you know the beginning and ending dates for the stay, you can make sure anything within those dates is lumped with the records for that hospital stay. Often patients come to the ER at night. They are there for a few hours and get admitted into the hospital in the wee hours after midnight. The discharge summary will probably cite the date the patient was actually accepted into the main hospital but you need to include the ER notes from “the day before” too. 

     Notes from a hospital stay will include all the notes from all personnel, test results, every single order that was ever placed, consent forms….. everything. Don’t rely on the hospital office workers to group the pages together in a sensible way. No one in the medical records department cares about saving you time. You will need to straighten up the mess they send you. Group the pages into the following sections and label them. You can do this in seconds (if your PDF has been OCR-processed) by running a search for these underlined terms. Once you find them, I would highlight the titles and dates then bookmark those pages. The attorney working on the case will love this. It helps everybody.

• “Emergency Department” notes
• “Progress Notes” or “Physician Notes” – These are the few notes that you should bother putting chronologically starting with the “Admission H&P” all the way through the daily “Progress Notes” and including any “Consultation Note” by specialists. 
• “Nurse’s Notes”- there will be a gigantic quantity of these. Forget about putting them in chronological order just lump them all together. The hospital electronic medical record systems are usually good about lumping these particular notes together chronologically anyway. 
• “Physical Therapy ”, “Occupational Therapy” and “Speech Therapy” Notes– these are often very helpful and give loads of information that the physicians themselves miss. The hospital electronic record systems usually do a terrible job of keeping these together. Grouping them all together in a bookmarked section called "therapy notes” would be great. Grouping them in three groups “PT, OT and ST” would be even better. 
• “Lab Results” – usually these will come grouped together. If not, just lump them all together and bookmark into a section. 
• “Radiology Results” - usually these will come grouped together. If not, just lump them all together and bookmark into a section. 
• “Procedure Notes” – these include “Operative Notes” (Pre-Op & Post-Op), “Code Notes”/ “Code-Blue Notes”, etc. Since a procedure, a surgery and almost dying are very important details, you should run a search for each of these underlined terms if there is any mention of these things happening in the all-important “Discharge Summary” mentioned earlier. If you find any of these procedure notes, highlight the titles and bookmark the page. They attorney working the case will love that.  
• "Discharge Summary" – I mentioned this above but I mention it again because it is a pivotal document. You should make sure it is the very last thing at the end of the hospital stay so that it is extremely easy to find for everyone, over and over again.   
• “Everything else” – at this point, if there are any notes left within the dates of the hospital stay, just lump them all together in a bookmarked section and put it right before the discharge papers. 

Hopefully all of this technology and organization helps you as much as it will help your expert witness. Your office staff may not like it because it means more time for them but if you are paying bills for a bustling law firm, whose hourly rate would you rather pay to do the above organization – your expert’s or your office staff? Any expert worth their salt is going to be doing all of this anyway unless they are the “second” kind of physician mentioned above. In that case, give them your nurse’s timeline, hope for the best but prepare for the worse in deposition. From a management perspective, you may wonder if this is more economical to hire out to a third party “medical record service”. In the short term, it may be. In the long term, these companies earn their living by convincing you that this work is too hard for your team to do and that your staff should not waste time on it. They hope to keep you in the dark about how easy this technology is.

If you embrace this technology, it could improve workflow processes in all parts of your practice. 

Wondershare’s PDFelement has been a terrific, cheaper alternative to Adobe with no subscription fees. I have found lots of how-to videos on their website and YouTube including an easy way to make a Table of Contents (or any list of citations) for a PDF that link the referenced number directly to the page within the body of the PDF. (https://youtu.be/_1xatndiXPA) Why pay another company to do that when one can learn how to do this in two minutes and then utilize it in all sorts of ways in your office? With everyone going paperless, why waste a single minute searching manually through PDF’s if one can OCR-process them and run instantaneous searches in them? Imagine how that could improve your efficiency in everything. Sumnotes.net is a forward-thinking internet service that allows you to upload an OCR-processed PDF that you have highlighted.  It then extracts any text you highlighted and gives you the option to export it into a Word document, onto the clipboard, etc. Loading OCR-processed PDF’s onto an iPad with an Apple Pencil will allow you to highlight PDF’s and work in airplanes even if there is terrible internet service on them. Storing these in a cloud service will instantly sync your work across all of your devices anywhere. With automation available through Zapier, Coda, Google Sheets, Google Docs and others, you can even build automations to reduce hours of staff time and eliminate the need to pay expensive third parties for things you can do with the push of a button.  This is efficiency.  If ever hired as an expert witness on your case, I am happy to talk to your office staff about all of this.