Below is a very lengthy excerpt of my letter to MBC staff Curt Worden, providing crucial background information for the August 7th “Interested Parties” meeting.
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Unfortunately, I am unable to attend the scheduled Interested Parties meeting scheduled later this week. I expect someday professionals and members of the public will be able to provide information and ask questions via Skype or other 2-way communication technology.
In the mean time, all I can do is provide these ideas in writing, so the MBC staff will know that members of the California College of Midwives have the following concerns and requests.
I’m sure that CAM members have voiced many of the same concerns and are interested in similar solutions.
Pertinent Background Information about LM hospital transfers/EMS transports:
A. Receiving OBs at the hospital frequently tell the transferring LM that they don’t want to see or read the midwife’s labor or other intrapartum records, and are only interested in the mother’s prenatal lab work and ultrasound reports.
B. Receiving OBs at the hospital tell the LM that federal HIPPA regulations protecting ‘patient confidentiality’ prohibit them from even looking at the mother’s mfry chart. While the laboring woman is herself only a few few away and the physician (if s/he believed it necessary) could easily get verbal or written consent, this option is NOT considered.
C. Even though a receiving OB has taken a report from the LM and fully viewed the patient’s chart, the NICU doctors and nurses usually have no direct information about the mother’s pre-admission mfry care, the birth or other factors relative to the baby’s situation.
In more than one instance, NICU staff and perinatologists repeatedly remarked to both parents that their baby’s problem was directly the result of not planning or not having a hospital birth. This lack of accurate information makes a difficult situation even worse for the parents, and yet a totally painless and effective solution can easily be provided were this problem to be formally acknowledged.
D. CCM members and other CA LMs quite reasonably want to read the hospital’s MBC LM-transfer report to be sure it correctly reflects the actual facts of the case.
A hospital transfer report filled out by a physician who previously refused to read the transferring midwife’ chart does not have a complete or accurate picture of mfry care provided, or knowledge of the actual circumstances of the case. This is a very unsatisfactory situation, especially when the name and license # of the LM are included on the documents sent to the California Maternal Quality Care Collaborative (CQMCC).
AB 1308 stipulated that all these LM hospital reports be copied and provided to the CMQCC. It must be noted that this organization is a Stanford University-hosted NGO, and not in any way an agency of California government. The office staff of the CMQCC do not currently have any legally-stipulated responsibilities relative the protecting identify of the LM, or for that matter, any other aspects of the information provided to them in copies of the MBC’s LM Transfer reports.
In light of these factors, CCM members request the following 4 actions by the MBC:
1. An article in the Action Report identifying the legal responsibility of the receiving physician to, at the very least, familiarize him or herself with the content of the transfering LM’s intrapartum chart.
While information in the mother’s prenatal chart is some what useful, in general it has little to do with the actual facts of the labor. However, knowledge of the intrapartum chart is necessary to provide crucial information on antecedent issues, and/or the proximal medical conditions that necessitated an intrapartum transfer of care or EMS transport.
The mother’s intrapartum chart is only a few pages (or less) in length. The legal obligation to provide clinically appropriate care should be enough of a reason for the attending OB to review the midwife’s labor or birth records prior to making treatment decisions. In event of malpractice litigation associated with a subsequent ‘adverse event’, I hate to have to swear under oath that as the attending obstetricians, I hadn’t bothered to read the LM’s intrapartum record before I ordered potentially risky medical treatments or performed major surgery of the laboring woman.
However, it is also absolutely necessary that the physician who will later be filling out the MBC’s Intrapartum Hospital Transfer Form (if different than the receiving MD) also review intrapartum records, even if it was the baby who required transfer after being born at home.
Any thing less than this is a failure of ‘due diligence’ on the part of the MD providing care and/or the MD who subsequently makes the official report as required by the California Legislature when it passed AB 1308.
2. A legal opinion by the Board’s own Counsel and/or the AG’s office as to whether a reasonable-person interpretation of the federal HIPPA regulations prevents hospital OBs from looking at a mfry client’s intrapartum chart.
I must note here that personnel for EMS also produce and provide legal records outlining the facts of the EMS hospital transport. This applies equally to childbirth-related as well as all non-obstetrical emergencies. This includes the time notified, time of arrival, assessment of the medical situation, emergent care provided by EMTs, etc. In regard to laboring women, these records are universally transmitted verbally upon arrival at the ER and again to the receiving OB in the OB department.
A hard-copy of theEMS report is also included in the patient’s hospital chart. Attending physician are legally responsible for knowing the facts about pre-hospitalization treatments by EMS and other pertinent information in the EMS patient-care record.
Any legal ruling by the MBC or AG relative to the implications of HHIPA would need to reconcile facts about the current customary sharing of EMS information with hospital personnel and the same process of verbal and written information as shared by the LM under very similar circumstances.
3. We also ask that the LM involved in a hospital transfer be able to access a copy of the hospital report submitted to the MBC.
At the very least, we should be able to read the report about a transfers of our client after its filled with the MBC. If the information provided was inaccurate, this allows us to to provide corrective information by contacting the individual physician personally or in writing. A written copy of corrective information should also be sent to the MBC and included as an addendum to that particular transfer report.
4. We ask that the LM’s name be redacted before copies of the MBC’s LM Hospital Transfer reports are forwarded to the CMQCC.
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I am attaching a copy of the CCM’s new hospital transfer form for LM {by clicking on the link below, it will automatically download to your computer. You can be opened by clicking on the title in your “Downloads” folder
CCM form_hosp-tranfer-transport_August-2014.
It was designed to provide specific information about the circumstances prior to and during an elective hospital transfer or EMS transport. It provides specific metrics about the lengths of the various stages of labor, and other information to help the staff better understand the mfry care received prior to the client or baby developing issues of concern. It also provides the proximal reason/s requiring hospitalization and access to the facts used to decide when and how to transfer.
This CCM form will become a permanent part of the client’s record, but in some emergency situations the LM will not be able to complete the report before the mother or baby’s hospital admission. However the midwife should easily be able to finish this handwritten form after the mother or baby’s care is taken over by the hospital. At that point, a copy of it will also be provide to the OB staff and added to the client’s record of midwifery care. This is also how EMS emergency transport records are handled.
In addition, we believe that the baby’s hospital chart should have a copy of the LM’s pre- & intra-transfer report. This would provide the NICU staff and physicians with access to factual information and, one hopes, reduce the likelihood of an inappropriate “rush to judgment” as noted above (issue C).
In Conclusion:
We feel strongly that all the pertinent facts surrounding a hospital transfer are necessary in order to fully understand the situation. Full knowledge of the facts are equally necessary before any conclusions of legal merit (such as a designation of substandard, negligent or incompetent care by an expert reviewer/expert witness) can be reached on the quality of the care provided by the Ca LM relative to a specific hospital transfer.
MBC LM-client hospital transfer reports may be used by MBC employees, consultants and expert reviewers to determine the ‘merit’ of a complaint lodged against an individual LM. Considering the possible legal impact of these documents, our organization considers it a matter of legal ‘due diligence’ that any professional who has the authority and responsibility to report LM-client hospital transfers obtained full information prior to filing such reports.
In addition, we see nothing in the legislative language of AB 1308 that would prevent the MBC from redacting the name and license number in LM-client hospital transfers before providing copies to the CMQCC. Therefore we ask that the LM names and license numbers be electronically deleted or physically redacted before any of these records are electronically forwarded or mailed to the CMQCC.
On behalf of CCM members and the childbearing families we serve, we respectfully ask that the MBC as the regulatory agency for Ca LMs carefully consider the four enumerated requests, and if at all possible implement them in association with the Board’s duties pursuant to AB 1308.
The contents of this email should also be provided to any MBC-DCA attorneys scheduled to provide legal council to the Board during the August 7th Interested Parties meeting, and the August 14th meeting of the Mfry Advisory Council.