Patient Access and Amendment to Medical Records

Hello readers. I am not a writer but I just maintain and write blog posts for this website / blog as its rightful owner.

Like most writers, I too have become an inveterate procrastinator. In the course of writing for this website / blog, I had actually dumped my gold standard and writing policy to make sure that I have at least written frequently something that someone would actually want to read over the past months.

As 2015 is fading away, here I have now this new post and hope to endeavour with more posts into 2016 and also take a moment to breathe and probably as psyched as you may have watched Kylo Ren in Star Wars: The Force Awakens who has the following dialogue, “Nothing will stand in our way. I will finish what you started.”, and now say to myself and tell you readers that “Nothing will stand in my way. I will finish what I started.”, by finishing some unfinished blog posts in the course of 2015 and continue to write in MRPALSMY.

Paper-based medical record practitioners, doctors and healthcare management have been influenced for example after attending healthcare conferences and lured by vendors of the promise that Electronic Medical Records (EMRs) were supposed to improve patient care and make doctors’ lives easier, do away with paper documents, and provide greater governance and stewardship for medical records practitioners.

Unfortunately, the promise of how EMRs are supposed to be in theory, haven’t worked out as well in practice as they were to be.

A detailed report in the Chicago Tribune, laments how doctors in the U.S. are even looking forward to retiring because these doctors are crying out in pain over an increasing  “burnout“ to the demands of clicking through page after page of records.

Their predicament was compounded from the findings of a new 2015 survey by Accenture PLC which found that fewer U.S. doctors believe that the EMR has improved treatment decisions, reduced medical errors or improved health outcomes. This is compared to a similar study conducted in 2012.

Headquartered in Dublin, Ireland¸ Accenture PLC is the world’s largest consulting firm and as the world’s most admired Information Technology Services Company – providing multinational management consulting, technology services, and outsourcing.

Accenture PLC had commissioned a six-country online survey of 2,619 doctors to assess their adoption and attitudes toward electronic health records and healthcare IT. The survey conducted by Nielsen between December 2014 and January 2015 included doctors across six countries, which included neighboring Singapore (200 respondents) and the U.S. (601 respondents).

Another recent study by Mayo Clinic researchers, working with the American Medical Association, further strengthened the case against the use of EMRs which found that more than half of physicians felt emotionally exhausted. Heavier workloads and “increased clerical responsibilities.” were among the chief complains.

But all is not bad for EMRs.

There is evidence that EMRs are helping patients to get more access to their medical information.

In Malaysia, a patient’s medical record on which the paper it was printed on belongs to the medical practitioner and the healthcare facility and its services. Thus, the medical practitioner and the healthcare facility and its services hold all rights associated with ownership of the physical medical record.

Nonetheless, the contents of a medical record jointly belong morally and ethically between the practitioner and the patient, simply because the practitioner who wrote the medical record holds the intellectual property right over the medical record while the patient who confided with the practitioner considers his or her “confidential” information therein contained in the medical record as “private” in observance of the on-going ethical doctor-patient relationship.

This longstanding Malaysian, almost a decade old guideline on medical records by the Malaysian Medical Council concurs well with the universal and traditionally accepted view that the information contained within the health / medical record belonged to the individual patient, and the paper it was printed on belonged to the healthcare facility.

This guideline further acknowledges and asserts that since the patient views that all the information contained in his/her medical records (i) is about him/her, (ii) that he/she should have access to records containing information about his/her medical condition for legitimate purpose and in good faith between the practitioner and him/her, (iii) he/she has a right to know what personal information is recorded, (iv) rightfully expects the records are accurate, and (v) also knows who has access to his/her personal information.

The patient’s views that all the information contained in his/her medical records (i) is about him/her, (ii) that he/she should have access to records containing information about his/her medical condition for legitimate purpose and in good faith between the practitioner and him/her, is supported by the findings from the 2015 Accenture study which shows there is evidence in the U.S. in particular, that increased access to online medical records in particular has provided patients (55 percent) with better understanding of their illness as well as having a positive impact on patient-doctor relationship.

While patients have right of such access to their medical records, the Malaysian guideline does not say if patients may be permitted to make their own changes to the mostly paper-based medical record systems available in Malaysia, and stops at proclaiming that the Malaysian patient rightfully expects the records are accurate.

The 2015 Accenture study also does not report if patients are allowed to alter medical records in the U.S., but reports that patients there do monitor their medical records and inform the practitioner of any factual errors in their personal patient information and seek to change any entries made by the practitioner in the course of consultation, diagnosis and management, thus increasing the accuracy of their medical records (60 percent).

I rest the case for EMRs that promises better patient care, which is accentuated by findings from the Accenture survey that a high percentage (82 percent of respondents) of U.S. patients when allowed by their doctors to update their own medical records, it increases their engagement in their own health as well as improves patient satisfaction, boosts understanding of their health conditions, increases patient and physician communication.

Readers can view an infographic below which summarises the 2015 Accenture study.

2015 Healthcare IT Check-Up Shows Progress (And Some Pain)

Infographic credit: Accenture PLC

In Malaysia, since we do not have specific laws or regulations that address how amendments should be processed in medical records, I think it is about time healthcare organisations in Malaysia structure their practices to comply with the greater awareness and requirements of patients’ rights and the promise of better health care in Malaysia through both paper-based and electronic medical records.

References:

  1. Accenture, 2015, Accenture doctors survey 2015: Healthcare IT pain and progress, Accenture PLC, [https://www.accenture.com/us-en/insight-accenture-doctors-survey-2015-healthcare-it-pain-progress.aspx]
  2. John, R 2015, Beleaguered by electronic record mandates, some doctors burning out, Chicago Tribune, [http://www.chicagotribune.com/business/ct-doctors-hate-records-mandate-1213-biz-20151211-story.html#]
  3. Malaysian Medical Council , 2006, Medical Records And Medical Reports, Guideline Of The Malaysian Medical Council, http://mmc.gov.my/v1/docs/Medical%20Records%20&%20Medical%20Reports.pdf]
  4. Patricia, C 2011, Patient Access and Amendment to Health Records (Updated), American Health Information Management Association (AHIMA), [http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048587.hcsp?dDocName=bok1_048587\]

A doctor’s touch vs documentation and fitting things into boxes on computer screens

Writing narratives in paper based medical records is the usual way the team of healthcare professionals taking care of the patient – doctors and nurses largely record in the medical record to tell a story about what is happening to the patient and what occurred in the course of care. Such narratives are considered to be essential for communication between members of  healthcare professionals.

Following the advent of the Electronic Medical Record (EMR) / Electronic Health Record (EHR), doctors and nurses find the loss of space in the patient record to write narratives. The freedom of being able to describe something in a doctor’s or nurse’s own words is now replaced by structured drop-down menus, a prominent feature of EMRs / EHRs.

I like to share an essay, “Checking Boxes” about the frustrations and misgivings of a primary-care doctor who makes house calls in and around Tuscaloosa, Alabama, United States of America. Read this essay here.

The notion is that many caring doctors and nurses still wish to spend their time speaking and caring for patients rather than been overwhelmed with computer documentation and fitting things into boxes on computer screens.

References:

Regina, H 2013, Checking Boxes, 18 October 2013, Pulse–voices from the heart of medicine, viewed 27 Nov 2013, <http://www.pulsemagazine.org/archive/stories/310-checking-boxes>

Five Reasons Why Electronic Medical Records Are Good For Patients

Investment in developing a good Electronic Medical Record (EMR) system to provide value to patients by driving up safety, quality, operational excellence, transparency and access can be seen as shown by the example at Cleveland Clinic Abu Dhabi, a carefully designed EMR system modelled after the famous EMR model at Cleveland Clinic, Ohio, United States – a long time leader in EMR systems.

The infographic below (click on the image to open in a new tab of your current window to view a larger image) shows a summary of five (5) good reasons why EMRs are good for patients as from the example at Cleveland Clinic Abu Dhabi.

Reasons-Why-Electronic-Medical-Records-Are-Good-For-Patients

References:

  1. Five Reasons Why Electronic Medical Records Are Good For Patients, Marc, H 2013, LinkedIn, viewed 15 July 2013, <http://www.linkedin.com/influencers/20130715101824-13527628-five-reasons-why-electronic-medical-records-are-good-for-patients>

Electronic vs Paper medical records – tracking down John Doe’s medical records

Many Health Information Management (HIM) / Medical Records (MR) practitioners worldwide are still stuck with the conventional paper based medical record. The infographic in this post (you can view a larger image by first clicking on the image below which will open in a new tab of your current window and then clicking again on the image in the new tab) is a typical scenario of “missing” medical records, and offsite storage which continues to post many problems from logistics to damaged medical records.

Electronic medical records seems to drive greater efficiency in storage of medical information, and it seems to me perhaps as the best possible path and solution for the betterment of medical records management. HIM / MR practitioners practicing in such an environment will know its impact.

Electronic vs Paper medical records

Infographic credit : medefile.com/blog/

Whither paper-based medical records systems?

I have this infographic (below) to share which shows how as technology has advanced over the last 50 years (from 1960 till today), yet most of us accept that medical records are still kept in paper files, and that’s the way it is. Technology has evolved over those many years and has brought sweeping changes, brought about many changes, whither paper-based medical records systems?

Infographic credit : infographiclist.com

Since back in the mid 70s when I started my career in Health Information Management (HIM) / Medical Records (MR) Management  there is no way I would ever have dreamt of where we are technologically today. I wonder what our medical records systems will be like in 2020 technologically, when Malaysia envisions to be a developed nation.

2020 is just under 8 years more to arrive, meanwhile have we thought how much time is being wasted on paper activities that could so easily be streamlined?

This is how it looks (below) at a typical medical records department here in Malaysia.

Image credit : Hospital Universiti Sains Malaysia (HUSM) – Active medical record folders, Medical Records Unit

Is your life as an HIM / MR practitioner going to become easier – and much more organised if we moved to computer-based medical records, lured by the promise that once you move to a paperless way of organising things?

Talk about getting rid of paper, I hope hospitals everywhere can go from a large file room with tons of paper in files to a large server with high-tech programs, surely we’ve saved thousands of trees and dollars by doing so.

Below is what you can expect if we do away with paper.

Image credit : gobartimes.org/

Although access online is available 24/7 for everything from shopping to helping with homework, it is not available for medical records. Patients, doctors and other caregivers who rely on the medical system may find themselves in a dire situation when data about the most critical information about health and quality of life can’t be accessed in a timely manner that would and should guide future treatment. Yet it ought to be. The cost comes in wasted time, diminished quality of care, duplicate testing, needless expense, unnecessary worry and, worst of all, in lives lost.

Is then the paper-based medical records system not good enough anymore?

The technology applied in ATMs and on-line banking provide universal access to financial records, and one can access them on-line, too. The paper-based system of medical information currently in use has no connectivity, no ease of access for either patients or providers, and limited security and tracking of access. It is a barrier to improved treatment. This kind of technology could and should be applied to healthcare as it means more than convenience, this technology will definitely save lives. What is needed, is making the connection, and I think the technological answer to the need is within reach.

I hope for the day is not far off when we can walk into a HIM/MR department of a hospital and not see anymore medical records still kept in paper files!