Electronic health records (EHR) have taken over the daunting task of maintaining the medical information of millions of patients. In the interest of providing medical care that is well integrated, databases of these records are shared among hospitals and healthcare facilities.
But what if an error is made and propagated to the records in other facilities and keeps propagating again and again and again? The error becomes harder to untangle from the original database and all the others that quickly incorporated it in the interests of medical care.
Consider how one drop-down menu mistake for a patient’s medication might introduce bias in treatment into the record. But who would know it was a mistake if the patient never saw their record and felt there was no reason to ask for a copy?
The law is on the patient’s side, but facilities may not always be so willing to release the records. There is an exception where the facility could argue that the information would somehow harm the patient. Harmful to know what’s in your record? Are we children? How and when can a patient be refused access?
With limited exceptions, the HIPAA Privacy Rule (the Privacy Rule) provides individuals with a legal, enforceable right to see and receive copies upon request of the information in their medical and other health records maintained by their health care providers and health plans.
If you want more information on HIPAA regulations and your rights, there is material, and you can also file a complaint online.
How might inaccurate information be placed in your EHR? Many medications have similar names, and there may be two names for the same drug (brand name and generic). If personnel are unfamiliar with all the names and select the wrong one from the computer drop-down menu, your record has that error in it. But would that be a significant problem for you? I think it might.
Medications for psychiatric disorders, if entered into your record as a prior medication or one to which you had an AE (adverse event/allergy), staff reviewing your record will see it. Healthcare personnel is as fallible and biased as anyone else, and they may make certain assumptions about your mental state.
Any other medications that may have been entered incorrectly could also affect the treatments or drugs used in someone’s care. In any case, errors must be corrected, and the facilities that house them in their databases are required to make the adjustments.
Should everyone request a complete copy of their medical records? It’s a personal choice, but keeping your records ensures that you know what is in them, and you can have peace of mind knowing there are no untoward errors about which you were unaware.
Previously, requesting these records meant paying at least $1/page in some states, but today the entire thing can be burned onto a CD/DVD or put on a thumb drive. It’s not cumbersome and can easily be scanned for material information you want to select within the file. Remember that “pdf” documents have that “find” feature.
Obtaining medical records for yourself, a child, or a family member requires that you know the procedures. Here is a website that provides much of this information.
Have you looked at your medical records lately?