As doctors and hospitals switch to electronic medical record systems and try to amp up the business efficiency of their enterprises by opening online consumer portals, more patients may access their caregivers’ files on them, including doctor notes that may be shocking in their inaccuracy.
Heather Gantzer, a doctor practicing at Methodist Hospital in St. Louis Park, Minn., and immediate past chair of the American College of Physicians’ Board of Regents, told Cheryl Clark, a contributor to the MedPage Today medical news site:
“100% of medical records have errors. Some of them are nuisances, but some are really impactful and might make a huge difference for [example for] the person who was said to be on antibiotics” but was not.”
Clark cited other inaccuracies that patients have found in doctors notes that are part of their medical records, which federal officials have campaigned to make more accessible to consumers:
“One patient told MedPage Today she was shocked to read in her [primary care physician’s] visit summary that she was a ‘binge-drinker.’ What she actually told her doctor, in response to his question about how much she drank, was that she might have a few drinks when she was out with friends. She asked another provider in the same practice to delete that phrase but hasn’t checked whether her request was implemented. Another patient’s physician note said she’d undergone a course of antibiotics and nasal sprays for a cough that were ineffective when those were never prescribed or tried.
“This reporter was not able to see her own physicians’ recent visit summary notes through two of her doctors’ health portals, and when she did get copies by mail, forwarded by her primary care provider, they were full of errors. There was a drug on the active medication list that hadn’t been taken in years and symptoms listed that weren’t discussed or didn’t exist. A problem that resolved 20 years ago was listed as a current assessment. One report listed [a diagnosis and billing] code … for ‘abnormal weight loss’ as one of her problems when, as she told her doctor, she had been aggressively dieting and exercising for three months on advice of her [primary care physician] and had lost 30 pounds.”
These kinds of errors can become serious and harmful medical issues, pronto, with Gantzer saying, for example, that a mistaken notation that a patient previously had an appendix removed might put emergency room doctors off a fast, correct diagnosis of abdominal pain caused by appendicitis.
Erroneous material crops up in notes in patient records for various reasons, MedPage Today reported, in part quoting Fabienne Bourgeois, a doctor and first author of a study on the issue, as well as an attending physician and associate chief medical information officer at Boston Children’s Hospital:
“Errors are so common, Bourgeois [said], because, while a few physicians may write their notes during the patient visit, that’s not the usual practice. ‘A lot of this happens after hours, late in the evening or the next day,’ Bourgeois said. ‘Some clinicians are seeing 30 patients a day and documenting during that visit is not an option. It’s chaotic ….’ [And] ‘Docs rarely proofread our dictations, which are more poorly transcribed in some systems than others,’ said one neurologist who asked not to be quoted by name … Ted Mazer, a semi-retired San Diego otolaryngologist and a past president of the California Medical Association, noted that in many cases, ‘you have transcriptionists who are not quite getting the story but are going as fast as they can. Or electronic records have drop down menus that “look like” what’s right. So, you click. Or the doctor puts in the closest [billing and diagnosis] code, which is not going to be 100% accurate every time.’ A major problem, he acknowledged, is ‘nobody ever cleans up the record’ … Gantzer said that many errors occur from computer-generated templates, like “pulse in feet intact” when the patient is actually a bilateral amputee,’ or [due to] cutting and pasting other doctors’ notes.”
Whatever the source of possible errors, doctors and hospitals must work hard to make notes and patient records accurate and accessible, with ease, convenience, and without excess cost. Health staff also must be open to discuss with patients any notes or records they have questions about, experts quoted by MedPage Today insisted. If errors exist, they should be fixed, quickly and without a fuss.
That’s an excellent idea. In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care — and to understand and have control of what’s happening to them and their loved ones in a daunting system. Health care has become an ordeal for patients due to its skyrocketing complexity, uncertainty, and cost for treatments and prescription medications, too many of which turn out to be dangerous drugs.
Doctors make it their prime order of business in taking on a patient’s care to tackle a singular chore — to look fast and first at the individual’s health record. The information therein does not belong to care givers or any system — it is patients’ “property.” And if it is so crucial to patients’ care, they should not only own it but be able to get it, see it, and, yes, to have it explained to them, in detail, as part of their fundamental right to informed consent. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.
In my book, “The Life You Save, Nine Steps to Finding the Best Medical Care – and Avoiding the Worst,” I list getting and reading these documents for patients as step one to improve your medical care. Seeing and studying your medical record can provide you with invaluable information and insights about your health and conditions, their sustained care, and how well you and your doctor are communicating and understanding each other about it. You’ll learn a ton about how good your doctor is or isn’t. You’ll get an eye-opening and new view of your doctors and your care. Talk to your providers, correct errors, and misapprehensions, and stay atop those records to ensure, for example, that doctors don’t order duplicative tests or procedures, or that nurses and other clinical staff don’t list wrong medications or treatments
Doctors and hospitals may throw up obstacles to getting your own records. Don’t be deterred. And don’t let others compromise the privacy of your health records, electronic or otherwise. This is becoming a significant worry for hospitals and health care systems and you may wish to talk with your doctors and care giving institutions to see what steps they may be taking and what public support they may need to deter hackers.