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.


  1. Accenture, 2015, Accenture doctors survey 2015: Healthcare IT pain and progress, Accenture PLC, []
  2. John, R 2015, Beleaguered by electronic record mandates, some doctors burning out, Chicago Tribune, []
  3. Malaysian Medical Council , 2006, Medical Records And Medical Reports, Guideline Of The Malaysian Medical Council,]
  4. Patricia, C 2011, Patient Access and Amendment to Health Records (Updated), American Health Information Management Association (AHIMA), [\]

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