1 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 TONI L. BIANCHI, Executrix of the Estate of FRANCES R. 4 BRONCACCIO, Deceased, 5 Plaintiff, 6 -vs- CASE NO. 370551 7 8 KAISER FOUNDATION HEALTH PLAN OF OHIO, et al., 9 Defendants. 10 11 - - - - 12 Deposition of NEAL KAFOREY, M.D., taken as if 13 upon cross-examination before Laura L. Ware, a 14 Notary Public within and for the State of Ohio, at 15 Kaiser Permanente Medical Center, 12301 Snow Road, 16 2nd Floor, Administration Conference Room, 17 Cleveland, Ohio, at 9:10 a.m. on Monday, August 16, 18 1999, pursuant to notice and/or stipulations of 19 counsel, on behalf of the Plaintiff in this cause. 20 21 - - - - 22 WARE REPORTING SERVICE 23 3860 WOOSTER ROAD ROCKY RIVER, OH 44116 24 (216) 533-7606 FAX (440) 333-0745 25 2 1 APPEARANCES: 2 Mark W. Ruf, Esq. Hoyt Block Building, Suite 300 3 700 West St. Clair Avenue Cleveland, Ohio 44113 4 (216) 687-1999, 5 On behalf of the Plaintiff; 6 Susan M. Reinker, Esq. Bonezzi, Switzer, Murphy & Polito 7 1400 Leader Building 526 Superior Avenue 8 Cleveland, Ohio 44114 (216) 875-2767, 9 On behalf of the Defendants. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3 1 NEAL KAFOREY, M.D., of lawful age, called by 2 the Plaintiff for the purpose of cross-examination, 3 as provided by the Rules of Civil Procedure, being 4 by me first duly sworn, as hereinafter certified, 5 deposed and said as follows: 6 CROSS-EXAMINATION OF NEAL KAFOREY, M.D. 7 BY MR. RUF: 8 Q. Could you please state your name and spell your 9 name. 10 A. Neal Kaforey, N-E-A-L, K-A-F, as in Frank, O-R-E-Y. 11 Q. What is your address? 12 A. 2271 Cross Creek Trail, three words. That's 13 Cuyahoga Falls, Ohio, 44223. 14 Q. Dr. Kaforey, my name is Mark Ruf. I represent the 15 Estate of Frances Broncaccio in a lawsuit that's 16 been brought against Kaiser. 17 If at any time I ask you a question and you do 18 not understand my question, please tell me. If you 19 give me an answer to a question, I'll assume that 20 you have understood the question. Okay? 21 A. Yes. 22 Q. Who is your employer? 23 A. The Ohio Medical -- excuse me, the Ohio Medical 24 Permanente Group. 25 Q. And how long have you been employed by Ohio Medical 4 1 Permanente Group? 2 A. Since January of 1995. 3 Q. When did you graduate from medical school? 4 A. In 1981. 5 Q. Where did you work from '81 to '95? 6 A. '81 through '84 I did my emergency medicine 7 residency at Akron City Hospital, now called SUMMA. 8 And from 1984 through December of 1994 I was 9 employed by Canton Aultman Emergency Physicians, 10 Canton, Ohio, Aultman Hospital. That's 11 A-U-L-T-M-A-N. 12 Q. Are you board certified in any area of medicine? 13 A. Yes, I'm board certified in emergency medicine. 14 Q. When did you receive board certification? 15 A. In 1986. 16 Q. Do you have a supervisory position with Ohio 17 Permanente Medical Group? 18 A. Yes, sir. I'm the Chief of Emergency Services. 19 Q. Do you actually practice medicine as an ER doctor, 20 or is your position solely administrative? 21 A. I do both. 22 Q. What percentage of your time is administrative as 23 opposed to practicing ER medicine? 24 A. It's a 50/50 split, half time in the emergency 25 department, half time administrative. 5 1 Q. Do you only supervise doctors or all personnel in 2 the ER? 3 A. Just the physicians. 4 Q. How many doctors do you supervise? 5 A. I need to amend that. I supervise the physicians 6 and the physician assistants, PAs, and that would be 7 a total of approximately now 30. 8 Q. Are you involved in the training of emergency 9 personnel? 10 A. Not directly. We do not have an emergency medicine 11 residency program, but we participate with several 12 training programs in the area for education of PA 13 students and EMT students and advanced practice 14 nurses. 15 Q. Do you have any in-house training for emergency room 16 physicians? 17 A. No, we do not. 18 Q. Is the ER staffed by Ohio Permanente Medical Group 19 employees or are outside corporations or agencies 20 hired to do that? 21 A. Currently we have almost everyone employed by OPMG. 22 Up to the last month or so we had a moonlighting 23 group that was providing some moonlighting help and 24 that was Bethel, B-E-T-H-E-L. 25 Q. But the Bethel physicians would be hired to work for 6 1 the Ohio Permanente Medical Group? 2 A. Correct. 3 Q. Did you do anything to review the qualifications of 4 the physicians that were hired from the Bethel 5 group? 6 A. The Ohio Permanente Medical Group has a credentials 7 committee. 8 Q. And all the physicians that worked in the ER from 9 Bethel had to go through the credentials committee? 10 A. The same credentialing process, yes. 11 Q. Are you part of a peer review group here at Kaiser? 12 MS. REINKER: Objection. 13 A. Yes. 14 Q. Do you know where a patient's records are stored; 15 are they stored only in a hard copy file, or are 16 they also stored on computer? 17 A. I actually don't know where they are stored, but 18 there is a permanent paper copy and all emergency 19 department records are scanned into a computer 20 system. 21 Q. When an emergency room physician dictates a history, 22 physical and other information that's put into the 23 emergency room record, does it have to be 24 transcribed first or does the transcription 25 automatically go into the computer? 7 1 A. Do you mean like voice recognition software? 2 Q. Well, I don't know. Do they produce a hard copy and 3 then the hard copy is scanned into the computer? 4 A. Oh. 5 Q. Or is it typed into the computer system initially? 6 A. I'm not sure that I understand the specific meaning 7 of the question. 8 Q. Well, what do you know about the transcription 9 system? 10 MS. REINKER: At the present you mean? 11 I mean, it may have changed over time. 12 Q. Back in December of '97 what did you know about the 13 transcription system? 14 A. The transcription system was a contracted provider 15 contracted for and paid for by Kaiser Permanente, 16 and we accessed it by dialing a number and dictating 17 the chart. However, not all charts are dictated, 18 many are handwritten. 19 Q. Is the transcription service on site here at Kaiser 20 or are they off site? 21 A. It's off site. 22 Q. So if you would call up this number and dictate, how 23 would the transcription be produced and get into the 24 patient's record? 25 A. The process is that -- I suppose it's like a black 8 1 box to me. You dictate into it and a final record 2 is produced, but what the actual mechanics of the 3 contracted company are I do not know, but they 4 upload the final dictated transcribed version to the 5 Kaiser mainframe. 6 Q. Do you know the Kaiser employee that's in charge of 7 the mainframe? 8 A. I do not. 9 Q. Is there a computer department here at Kaiser? 10 A. Not in Ohio, no. 11 Q. That's at a corporate office someplace? 12 A. Yes. 13 Q. Do you know where that is? 14 A. I believe it's in Carina, California. 15 Q. How do you know that the records are uploaded to the 16 Kaiser mainframe? 17 A. I can search the Kaiser mainframe and find an 18 emergency department record for patients that have 19 been seen. 20 Q. What do you search in; is there a name? 21 A. Oh, the actual computer process itself? 22 Q. Yes. 23 A. It goes by two names. There is a front end 24 windowing system called ACCUMEN, A-C-C-U-M-E-N, and 25 there's also the -- the initials are EN 37. If you 9 1 type in EN 37 on a computer program called Extra, 2 you can find emergency department notes. 3 Q. What kind of information is kept on ACCUMEN? 4 A. That's where the emergency department records are. 5 Q. Is that the same for EN 37? 6 A. Yes. 7 Q. Do you know what the difference is between the two 8 of those? 9 A. Somebody wrote a windowing mouse menu interface for 10 the old 1960s mainframe EN 37 screen. 11 Q. So the ACCUMEN is the windows version? 12 A. Well, it's a windowing front end to the old 13 mainframe data. 14 Q. If you dictate an emergency room record, how long 15 does it take to get into the Kaiser system? 16 A. The contract says that they need to type it and 17 return it within 24 hours. 18 Q. Back in December of '97 was the independent company 19 fulfilling the contract in terms of typing in and 20 returning within 24 hours? 21 MS. REINKER: Objection. 22 A. I don't know. 23 Q. In general, based on your experience, was the 24 dictation transcribed and returned within 25 approximately 24 hours? 10 1 A. Depended on the day of the week. They were a little 2 bit slower on weekends. 3 Q. Generally on weekends how long would it take? 4 A. They were a little bit slower. 5 Q. It might take a little bit more than 24 hours? 6 A. It could. 7 Q. Did it ever take more than 48 hours, in your 8 experience? 9 A. I did not provide oversight for that contract since 10 it was a Kaiser contract, so I can't give you any 11 actual date on that. 12 Q. Do you know who did provide oversight? 13 A. I do not know. 14 Q. And after the dictation was transcribed, how would 15 it be returned to Kaiser? 16 A. It would be -- as soon as it's typed, it's uploaded 17 to the mainframe. 18 Q. If an ER physician dictates the record, does the 19 physician have to review what's been transcribed and 20 sign the record? 21 A. A typed copy is printed in the emergency department 22 and placed in the physician's mailbox for his review 23 and signature. 24 Q. And how often is a typed copy printed out? 25 A. Whenever it's transcribed. 11 1 Q. Well, how is that kept track of? Are all the 2 records for the evening printed at one time or are 3 they individually printed? 4 A. Oh, I see. I can answer your question in this way. 5 Again, it's a black box to me, but the actual 6 process of how the transcription company does it, 7 the act of uploading is a two-part process. One 8 data stream gets sent to the printer in the 9 emergency department and the other data stream gets 10 sent to the mainframe, so as soon as it's typed it 11 prints in the emergency department. 12 Q. And then as soon as it's typed and printed then 13 somebody takes the hard copy and puts it in the 14 physician's mailbox? 15 A. Yes. 16 Q. Is there a requirement as to how much time can pass 17 before the physician has to review whatever has been 18 transcribed? 19 A. No. 20 Q. Do they have to review it and sign it before their 21 shift is over? 22 A. Oh, no, because, again, if the contract says that 23 they have to be returned within 24 hours, obviously 24 there's no physical way that the doctor would still 25 be there. 12 1 Q. So there's no time requirement at all for a 2 physician to review a record and sign it? 3 A. No. 4 Q. If a physician realizes that there's been a mistake 5 in either his dictation or the transcription, what 6 does a physician do? 7 A. They actually have two choices. They can pick up 8 the dictation telephone and dictate an addendum to 9 the chart, or most people just hand write an 10 addendum to the record dated the date that the 11 addendum is done. 12 Q. Do you know how often addendums are done to the 13 record? 14 A. I would have to say that it's fairly frequent. 15 There is a balance in many cases between when you 16 want to dictate the chart and when the patient is 17 finally complete. 18 Best example for that would be a patient going 19 for admission. You would like to have the history 20 and physical accompany them for admission, but then 21 you may not have the last five minutes or the last 22 ten minutes of their ER time documented in that 23 dictation. 24 Q. Were you Dr. Haluska's supervisor on December 7th 25 and 8th of '97? 13 1 A. Yes. 2 Q. Were you involved in Frances Broncaccio's care in 3 any way? 4 A. No. 5 Q. Have you reviewed her records? 6 A. Yes. 7 Q. When did you review her records? 8 A. The date of her death. 9 Q. December 8th? 10 A. If that's the date of the death, yes. 11 Q. Why did you review her records? 12 A. As Chief of the Emergency Services, it's my duty to 13 review any case of any patient who expires. 14 Q. And as a matter of practice you do that? 15 A. Yes. 16 Q. So reviewing Frances Broncaccio's records was not 17 because of some special circumstance, correct? 18 A. It was because of the circumstance of death. 19 Q. It's just because that's the common practice to 20 review the records any time there is a death? 21 A. Yes, sir. 22 Q. And what are you reviewing or looking for when you 23 review records when a patient has died? 24 A. You review the record. 25 Q. For what purpose? 14 1 MS. REINKER: Objection. 2 Q. Go ahead. You can answer. 3 MS. REINKER: You can answer. 4 A. I think the best way to describe it is does the 5 record stand as a whole, does it make sense if 6 someone comes in with an ankle sprain and 7 subsequently dies there is -- it doesn't make sense, 8 there's a disconnect. We look for those type of 9 inconsistencies. 10 Q. Well, are you looking to see whether the record is 11 complete or are you evaluating the care that the 12 person has been given? 13 MS. REINKER: Objection. I think 14 you're getting awfully close to quality review 15 type stuff here, Mark, and I don't know, at 16 some point I'm going to have him stop answering 17 any questions in this line. But is this a 18 quality review type of situation? 19 THE WITNESS: Any death would be a 20 quality review situation. 21 Q. When you reviewed Frances Broncaccio's records on 22 December 8th was anything missing from the record? 23 A. There was no physical exam documented in the 24 dictated note. 25 Q. And you noted that on December 8th when you reviewed 15 1 the record? 2 A. Yes. 3 Q. Did you do anything to make sure that the record was 4 completed? 5 A. I left a message for Dr. Haluska to complete his 6 physical exam for the patient as an addendum to the 7 record. 8 Q. When did you leave that message? 9 A. That day. 10 Q. And how did you leave the message, was it written, 11 oral? 12 A. I actually don't remember. 13 Q. If you wanted to leave a message for a physician, 14 how would you do that? 15 A. My normal practice would be to place a note in their 16 physician's mailbox, the same place that we would 17 keep the transcribed medical record for them to 18 review and to sign. 19 Q. Do you know after December 7th and 8th when Dr. 20 Haluska was scheduled to work again in the Kaiser 21 ER? 22 A. No, I don't know when he was scheduled to work. 23 Q. Did you personally speak with Dr. Haluska about the 24 missing physical exam? 25 A. When he gave me the addendum to the chart, yes. 16 1 Q. But before that you only communicated with him by 2 leaving some type of message for him? 3 A. Yes. 4 Q. When did you discuss the missing physical exam with 5 Dr. Haluska? 6 A. When he gave me his copy. 7 Q. Do you remember what you discussed with him? 8 A. I was concerned about the lack of the physical exam 9 in the chart and wanted him to complete the record. 10 Q. Do you remember the specific conversation you had? 11 A. No, I do not. 12 Q. Did you give any explanation to Dr. Haluska why the 13 physical exam did not make it into the record? 14 A. I would actually assume that he would have given me 15 that explanation. 16 Q. Do you have any idea why the physical exam did not 17 make it into the record? 18 A. I do not know. 19 Q. Did you tell Dr. Haluska that you would add his 20 handwritten physical exam to the record? 21 A. I submitted it as a part of the chart. 22 Q. Did you tell Dr. Haluska that you were going to add 23 it to the chart? 24 A. That was the purpose for doing the addendum. 25 Q. But my question is, did you tell Dr. Haluska that, 17 1 that you were adding this addendum to the chart? 2 A. Oh, yes, as I explained earlier, that if a patient's 3 chart needs an addendum it's either dictated or hand 4 written, so it's not unusual for that to occur. And 5 we have a mechanism for doing that, dating it, 6 timing it properly and submitting it to medical 7 records. 8 Q. Did you personally submit the addendum to the 9 medical records? 10 A. I put it in the medical records basket. 11 Q. Where is the medical records basket located? 12 A. There are several in the emergency department. 13 Q. And what happens to a document that's put in the 14 medical records basket? 15 A. There is a clerk from medical records that 16 circulates through the building on a 17 Monday-through-Friday basis and collects paper and 18 takes it to medical records. 19 Q. Did you give Dr. Haluska the instruction that he 20 should rewrite the physical exam as best as he could 21 remember on a piece of paper? 22 A. He would not be rewriting it since it had not been 23 written before. 24 Q. Would you have told him to write the physical exam 25 as best he could remember on a piece of paper? 18 1 A. Yes. 2 Q. Would that be the note you would have written to 3 him? 4 A. I believe that would be the substance of the note. 5 There's no physical exam, complete the chart. 6 Q. Did you give him any type of time requirement on 7 when the chart had to be completed? 8 A. No. 9 Q. Were you present when Dr. Haluska wrote the physical 10 exam? 11 A. Not that I'm aware of. 12 Q. Did you assist him in any way in writing the 13 physical exam? 14 A. No. 15 Q. Did you instruct him as to anything that should be 16 put into the physical exam? 17 A. No. 18 Q. Did you review the handwritten physical exam after 19 Dr. Haluska completed it? 20 A. Yes. 21 Q. When did you review the physical exam? 22 A. When he handed it to me. 23 Q. I'm handing you what's been previously marked as 24 Plaintiff's Exhibit 5. Is that the physical exam 25 that Dr. Haluska -- 19 1 MS. REINKER: Do you have an extra copy 2 of that, Mark? That's okay. I'll dig mine 3 out. 4 MR. RUF: Could you share it with Dr. 5 Kaforey? 6 MS. REINKER: Sure, or else I'll get my 7 own. 8 Q. Is Plaintiff's Exhibit 5 the handwritten physical 9 exam of Dr. Haluska for Frances Broncaccio? 10 A. This appears to be a copy of it, yes. 11 Q. When you talked to Dr. Haluska, was Plaintiff's 12 Exhibit 5 already written out? 13 A. Yes. 14 Q. And did you talk to Dr. Haluska about Plaintiff's 15 Exhibit 5, December 22nd, 1997? 16 A. I talked to him about the lack of the physical exam 17 on the chart, and he recalled the details of the 18 physical exam and said that he could not understand 19 why it had not been either dictated or transcribed. 20 He was unsure as to where the error occurred but it 21 was plainly not on the transcribed copy. 22 Q. And that's the discussion that occurred on December 23 22nd? 24 A. Yes. 25 Q. So before December 22nd you did not have any type of 20 1 oral discussion with Dr. Haluska about the missing 2 physical exam? 3 A. Not that I recall. 4 Q. Do you know what happened to the message that you 5 left for Dr. Haluska? 6 A. As I said, I don't even recall if I left him a phone 7 mail message or a written message, but my usual 8 practice would have been to put a written note in 9 his mailbox. 10 Q. I'm a little confused. When you talked to Dr. 11 Haluska on the 22nd, was Plaintiff's Exhibit 5 12 already completed or did you talk to him before he 13 wrote out Plaintiff's Exhibit 5? 14 A. Oh, I answered that I spoke to him as he handed me 15 the completed copy. 16 Q. And then you had the discussion that you previously 17 stated? 18 A. Yes. 19 Q. Did you tell Dr. Haluska anything else during that 20 conversation? 21 A. I believe that we discussed the case from start to 22 finish. 23 Q. What did you discuss with him? 24 MS. REINKER: Objection. 25 A. I believe that represents quality assurance 21 1 material. 2 Q. Did you have any other discussions with Dr. Haluska 3 that would not fall under the quality assurance? 4 A. About what? 5 Q. About anything. 6 MS. REINKER: Objection. I'm sure in 7 the years they worked together they had many 8 discussions. Do you want to make that more 9 narrow, Mark? 10 Q. About anything regarding Frances Broncaccio or the 11 missing records. 12 MS. REINKER: Well, objection to 13 missing records. 14 A. There were no missing records, they were incomplete 15 when he completed them. 16 Q. Did you have any other discussions with Dr. Haluska 17 that would not fall under quality assurance about 18 Frances Broncaccio? 19 A. Any discussions I would have with Dr. Haluska about 20 this case would have fallen under quality 21 assurance. 22 Q. Are you in charge of the quality assurance for 23 emergency room physicians? 24 A. Yes. 25 Q. Do you consider any impressions that you formed in 22 1 reviewing the records part of quality assurance? 2 A. Yes. 3 MS. REINKER: I'd like to note an 4 objection. If you'd like to ask the care 5 rendered, you can go right ahead and ask that. 6 Q. I'm sorry, did you answer yes to the last question? 7 A. Yes. 8 Q. How many times have you reviewed Frances 9 Broncaccio's records? 10 A. I don't know. 11 Q. Was it -- 12 A. I can state clearly that I have reviewed them within 13 the mechanism of quality assurance. 14 Q. Do you have any explanation for why the physical 15 exam was the only thing that was not transcribed? 16 A. I do not. 17 Q. Based on your experience, if a part of the dictation 18 is cut out, does a transcription service transcribe 19 whatever has been dictated? 20 A. Yes. And they just leave a blank for any area that 21 was blank. 22 Q. Was there any portion of Dr. Haluska's physical exam 23 that was not -- I'm sorry, strike that. 24 Was there any portion of Dr. Haluska's physical 25 exam that was transcribed? 23 1 A. I would have to refer to the medical record. 2 Q. What part of the medical record would you have to 3 refer to? 4 A. The emergency department record. 5 Q. So if there was a portion that was transcribed it 6 would be in the emergency department record? 7 A. If I can ask -- excuse me. If I can answer a 8 slightly different question, I can say that 9 sometimes on the emergency department record itself 10 there may be handwritten notes that physicians jot 11 down to utilize for when they do their dictation. 12 Some physicians do that, others don't. 13 Q. But other than the handwritten notes, if any portion 14 of the physical exam was transcribed it would be in 15 the record? 16 A. If it was transcribed it would be on the transcribed 17 copy of the dictation. 18 MR. RUF: I'm sorry, Susan, do you have 19 that; could he refer to that? 20 Q. Okay. Your counsel has been kind enough to provide 21 the actual transcription of the ER record. Could 22 you review that and tell me if any portion of Dr. 23 Haluska's physical exam was transcribed? 24 A. It is blank. 25 Q. So none of the physical examination was transcribed, 24 1 correct? 2 A. That's correct. 3 Q. In December of '97 do you know approximately how 4 many patients Dr. Haluska would see per evening? 5 A. I could not tell you that number off the top of my 6 head, mainly because it varies by time of day, day 7 of week. 8 Q. In the evening, generally, how many patients would 9 you see as an ER physician? 10 A. Again, you would have to define evening. We have, 11 you know, shifts from 7:00 a.m. to 4:00 p.m., 3:00 12 p.m. to midnight, 10:00 p.m. to 7:00 a.m., so which 13 shift do you want to consider as evening? 14 Q. 10:00 p.m. to 7:00 a.m. 15 A. He might see anywhere from 10 people to 30 people. 16 Q. What about the other shifts? 17 A. Well, Monday through Friday from 7:00 a.m. to 4:00 18 p.m. you might see 20 to 30 people. Saturdays and 19 Sundays would be a higher volume. 20 MS. REINKER: Which shift was that? 21 I'm sorry. 22 A. 7:00 A to 4:00 P. The second shift, from 3:00 p.m. 23 to midnight, has the highest volume of patients 24 Monday through Friday and on weekends. 25 Q. And generally how many patients would come in during 25 1 that time? 2 A. Well, that could be 30 to 50 patients. 3 Q. Do only Kaiser patients present to the ER at this 4 facility? 5 A. Actually, the answer to that is no. Under federal 6 law any person who presents to any emergency 7 department must be seen and a medical screening and 8 stabilization exam done, so anybody could present. 9 Q. Could you take a look at Plaintiff's Exhibit 5. Do 10 you know what the number is at the top, 21, dash, 11 89, dash, 13? 12 A. Yes, sir, that is the -- I assume it's the patient's 13 Kaiser medical record number. A six-digit number 14 separated by two dashes are utilized to represent an 15 MRN, medical record number. 16 Q. What is a medical record number, what's the purpose 17 of that? 18 A. It is analogous to a person's Social Security Number 19 or driver's license identification number. It is a 20 form of identification. 21 Q. Is that the patient's ID number through Kaiser? 22 A. Yes. 23 Q. Do they have another ID number that's different than 24 the medical records number? 25 A. Not that I'm aware of. 26 1 Q. Do you know what the 20 is that's circled at the top 2 of the page? 3 A. That would be her chart location, the place where 4 her primary care doctor is. We're just used to 5 dictating that. 6 Q. And what would be the chart location? 7 A. 20, which represents Parma. 8 Q. So her chart would be kept here at Parma? 9 A. Her primary care doctor is at Parma. 10 Q. I thought you said 20 was a chart location. 11 A. That is the term that the 20 represents, but within 12 the last five years Kaiser has centralized its 13 medical records to I believe one or two locations 14 rather than having medical records in a written form 15 located at each facility since they're now available 16 on the computer. A chart location no longer 17 represents the actual storage site. 18 Q. Do you know the date that Plaintiff's Exhibit 5 was 19 put into Frances Broncaccio's chart? 20 A. No, I would have no way of knowing that. 21 Q. But to the best of your knowledge it was put into 22 the medical records basket on December 22nd, 1997? 23 A. Yes, sir. 24 Q. And based on your experience, once you put a 25 document in the medical records basket, does it 27 1 generally go into the patient's chart that day? 2 A. I could not testify to that. I do not know how 3 Kaiser's medical records department operates for 4 loose leaf material. 5 Q. Can you think of any reason why Plaintiff's Exhibit 6 5 would not have been included in Frances 7 Broncaccio's records? 8 MS. REINKER: Objection. I mean, I 9 think he just testified he doesn't know how the 10 records operate. 11 A. With your indulgence, I would just like to point out 12 that Kaiser is a two-headed organism. There is 13 Kaiser as an insurance company and the Ohio 14 Permanente Medical Group. I represent the Ohio 15 Permanente Medical Group. So how things occur 16 within the Kaiser system for medical records, 17 contracts with vendors and all those types of 18 issues, I do not have information on that. 19 Q. Do you have any knowledge of the ordering of Frances 20 Broncaccio's records or the production of those 21 records? 22 A. To who? 23 Q. To anyone. 24 A. Oh, well, for example, myself. I obtained the chart 25 on the date that she died and reviewed them that 28 1 day. Any other requests for the records would 2 obviously go through medical records. 3 Q. So you have no knowledge of a medical records 4 request by Robert Bianchi? 5 A. I do not have any knowledge of any medical records 6 request. 7 MS. REINKER: Do you know the date of 8 that, Mark? 9 MR. RUF: No, not off the top of my 10 head. 11 MS. REINKER: Okay. 12 Q. Who's in charge of medical records here at Parma? 13 A. I don't know who's in charge of medical records at 14 Parma, but Marcy Kalatta, K-A-L-A-T-T-A, is the head 15 of Kaiser's medical records. 16 Q. Where is she located? 17 MS. REINKER: If you know. 18 A. I don't know. She exists as a phone number. 19 Q. Are there any medical records personnel here at the 20 Parma facility? 21 A. I don't know. I assume that there's a clerk who 22 comes and collects the materials from the medical 23 records basket, but I do not know where they go 24 beyond that. 25 Q. If you have a problem with medical records is Marcy 29 1 Kalatta the person that you call? 2 A. That's who I would call. 3 Q. Have you ever called or talked to anyone from 4 medical records other than Marcy Kalatta about a 5 medical records problem? 6 A. No. 7 Q. Do you know, is Marcy Kalatta a Kaiser employee? 8 A. She would be a Kaiser employee. 9 Q. Do you use an outside line or is there some type of 10 internal system that's used to call her? 11 A. I would actually communicate with her preferentially 12 by e-mail. 13 Q. If you wanted to reach her by telephone, how would 14 you do that? 15 A. I would look up her phone number in the Kaiser 16 directory. 17 Q. Do you know when Dr. Haluska stopped working in the 18 Kaiser ER? 19 A. I could get you that information, but I do not have 20 the actual last date that he worked off the top of 21 my head. 22 Q. And do you know why he stopped working in the Kaiser 23 ER? 24 MS. REINKER: Objection. He's asked 25 and answered that. Dr. Haluska has talked 30 1 about that. 2 MR. RUF: Well, I'd like to ask Dr. 3 Kaforey. 4 Q. Do you know why he stopped working in the Kaiser 5 ER? 6 A. Dr. Haluska had been employed by numerous emergency 7 departments in this area. Why he chose to stop 8 working for us, I do not know. 9 Q. Was it a voluntary choice on his part or was he 10 terminated? 11 MS. REINKER: Objection. 12 A. I believe you would have to ask him that. 13 Q. On the medical record does it list the date and time 14 when a physician dictates a history, physical exam 15 and other information? 16 A. Yes. It not only lists the time of the dictation, 17 it also lists the time of the actual transcription. 18 Q. And what does the posting date mean? 19 A. We will refer to the medical record again and I will 20 turn the page to you and say I assume dictated and 21 transcribed is the meaning of the D and the T, and 22 to my mind that represents the posting time as well. 23 Q. What is the posting time? 24 A. I assume that means the upload to the mainframe. 25 Q. What is the encounter system? 31 1 A. Every patient who presents to Kaiser Permanente for 2 any reason has a mainframe generated number called 3 the encounter number generated. That number is a 4 unique number and corresponds to that visit only. 5 Q. I'm handing you a printout from the encounter 6 system, and it says the date dictated, date 7 transcribed, and there's also at the top posted on. 8 What does the posted on mean? 9 MS. REINKER: I'm going to object 10 because he's not part of the Kaiser computer 11 staff, and I don't want you to be answering 12 questions if you're just guessing at things, 13 Doctor. 14 A. I can't answer it, I don't know. 15 THE WITNESS: Does this time 16 correspond? 17 MS. REINKER: Uh-uh. 18 THE WITNESS: No. 19 MS. REINKER: There's no question. 20 THE WITNESS: I know. 21 Q. Did you speak at all with any of Frances 22 Broncaccio's family members? 23 A. No, sir. 24 Q. If a family member or a patient requests to speak 25 with a doctor, is the nursing staff required to let 32 1 them speak with a physician? 2 A. You mean when the patient is in the emergency 3 department? 4 Q. Yes. 5 A. Oh, the patient is the patient. We do not violate 6 patient confidentiality by involving even family 7 members unless they have a Court designated reason 8 to speak for that member. 9 Q. If the family members ask to speak with a physician, 10 would that be the reason why they would not be able 11 to? 12 A. We would never violate the patient's 13 confidentiality. 14 Q. What if the family members were present in the room 15 with the patient when the patient was being cared 16 for? 17 A. I assume that they would need to discuss that 18 amongst themselves and come to some agreement. 19 Q. Well, would you discuss the patient's medical 20 condition with the family members if the patient 21 consented to that? 22 A. I would, yes. 23 Q. Do you provide any training to emergency room 24 physicians here at the Kaiser Parma facility as to 25 how to recognize signs or symptoms of myocardial 33 1 infarctions or aortic dissections? 2 A. No, we do not provide such training. We would 3 assume that that training should have been covered 4 in their education, residency and practice. 5 Q. Are there reference materials available to an 6 emergency room physician? 7 A. Some physicians carry textbooks with them when they 8 work, other physicians have left textbooks in the 9 emergency department on occasion, so there is 10 usually some sort of material available. 11 Q. Do you know what textbooks are in the emergency room 12 department? 13 A. Since they actually belong to individuals, I could 14 not tell you from day to day which textbooks are 15 there. 16 Q. Are there any textbooks that are kept there all the 17 time? 18 A. No. 19 Q. Is it up to an ER doctor to provide his own 20 reference materials? 21 A. I think that some emergency physicians when they are 22 fresh out of training tend to carry more textbooks 23 with them than experienced emergency physicians on 24 average. 25 Q. Well, my question is though Ohio Permanente Medical 34 1 Group and Kaiser do not provide any permanent 2 medical textbooks or medical references in the ER 3 department? 4 A. We do not. 5 Q. Is there a library here at the Kaiser Permanente 6 facility in Parma? 7 A. There is a medical library here on the second 8 floor. 9 Q. What are the hours of the medical library? 10 A. I don't know. 11 Q. Would the library be open at 11:00 in the evening? 12 A. I doubt it. The rest of the medical office building 13 where the library sits is closed. 14 Q. What time does the building close? 15 A. Whenever the last patient is seen in the medical 16 offices. 17 Q. Have you talked to anybody but Dr. Kaforey about the 18 missing physical exam? 19 MS. REINKER: Objection to the 20 characterization. 21 Q. Go ahead. 22 A. Can you read me the question back because it refers 23 to myself. 24 25 - - - - 35 1 (Thereupon, the requested portion of 2 the record was read by the Notary.) 3 - - - - 4 MS. REINKER: Objection. 5 Q. Go ahead. 6 MS. REINKER: Well, if he can get into 7 this without getting into any quality review 8 issues, otherwise I'm instructing him not to 9 answer. 10 A. But the question makes no sense. 11 MS. REINKER: Okay. 12 A. You asked me if I asked anybody other than myself. 13 Q. No, I said have you talked to anybody but Dr. 14 Kaforey about the omitted or missing physical exam. 15 A. That implies that I talked to myself? 16 Q. No, I'm not asking about yourself. 17 A. But you named me, you said did you talk to anybody 18 other than Dr. Kaforey, which is me. 19 Q. Oh, I'm sorry. Have you talked to anybody but Dr. 20 Haluska about the omitted or missing physical exam? 21 A. That falls under quality assurance. 22 MS. REINKER: Whether or not he did. 23 MR. RUF: Okay. Thank you. That's all 24 I have. 25 MS. REINKER: Could you hold on one 36 1 second. Off the record for one second. 2 - - - - 3 (Thereupon, a discussion was had off 4 the record.) 5 - - - - 6 MS. REINKER: I was just going back on 7 the record. Mr. Ruf has an interrogatory 8 pending which Dr. Kaforey was going to be 9 answering. 10 The question is list all of the 11 authors, editions and titles of textbooks that 12 were available in the Kaiser Parma Emergency 13 Room in 1997. 14 Rather than have us put this in 15 writing, do you want to just answer that for 16 him now? 17 THE WITNESS: I cannot tell you which 18 authors, editions or titles of textbooks were 19 available in December of 1997 because they 20 change periodically as people bring books in 21 and take their books home. 22 MS. REINKER: Fair enough. 23 MR. RUF: Okay. Thank you, Doctor. 24 MS. REINKER: Mr. Ruf, are you 25 satisfied with that answer so we don't have to 37 1 give a written answer to this interrogatory? 2 MR. RUF: Well, I'm not satisfied with 3 the answer, but I'll agree that that is your 4 answer to the interrogatory. 5 MS. REINKER: Okay. Thank you. 6 MR. RUF: What do you want to do about 7 signature? 8 THE WITNESS: I waive signature. 9 MS. REINKER: I don't want you to waive 10 signature. 11 THE WITNESS: I do. 12 MS. REINKER: I would prefer you take 13 the time to read this because occasionally 14 there are typographical errors and things like 15 that, so I would suggest you not waive 16 signature, that way we have a chance to look 17 over it before your signature is put on it. 18 THE WITNESS: Okay. 19 MS. REINKER: We do not waive 20 signature. 21 22 NEAL KAFOREY, M.D. 23 24 25 38 1 2 C E R T I F I C A T E 3 The State of Ohio, ) SS: 4 County of Cuyahoga.) 5 6 I, Laura L. Ware, a Notary Public within and for the State of Ohio, do hereby certify that the 7 within named witness, NEAL KAFOREY, M.D., was by me first duly sworn to testify the truth, the whole 8 truth, and nothing but the truth in the cause aforesaid; that the testimony then given was reduced 9 by me to stenotypy in the presence of said witness, subsequently transcribed into typewriting under my 10 direction, and that the foregoing is a true and correct transcript of the testimony so given as 11 aforesaid. 12 I do further certify that this deposition was taken at the time and place as specified in the 13 foregoing caption, and that I am not a relative, counsel or attorney of either party or otherwise 14 interested in the outcome of this action. 15 IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal of office at Cleveland, 16 Ohio, this day of , 1999. 17 18 Laura L. Ware, Ware Reporting Service 19 3860 Wooster Road, Rocky River, Ohio 44116 My commission expires May 17, 2003. 20 21 22 23 24 25