Find out whether your electronic medical record is accurate

Because someone rammed her SUV half-head-on into my car, this physician-surgeon has, of late, been a patient at physicians’ offices and outpatient surgical centers; and while medical sights, sounds, and sharp scalpels don’t scare me, one thing I’ve discovered about electronic medical records does.  They may not be accurate.

I love my profession. I am a stickler for accuracy, and I like reviewing patient charts. I always secure a copy of my own medical records simply because I like to be an informed patient. It was sometimes difficult to decipher some doctors’ scribble, but I discerned accurate documentation of my “HPI” — history of the present illness — as well as that of the exam performed, and pertinent findings.

But in this world of electronic medical (or health) records (EMR/EHR), I am no longer sure that such is always the case.

EMRs are helpful: physicians can review patient information that is typed and easy to access with the click of a mouse. But the physician’s entries must be as accurate as possible.

My concern is not an indictment of my personal physicians; I wouldn’t be their patient if I didn’t have confidence in them. But as a result of securing copies of my records, and seeing records of others, I am very concerned that with the implementation of EMRs, not everything that is documented is actually being done. A few times when reading my records I said, “He didn’t examine (or check for) that.”

Fortunately I understand what I’m reading. I also know what should be done as part of each portion of an exam. The layperson doesn’t have this benefit.

I fear that clinicians may rely on the EMR to literally “fill in the blanks” of examinations not done. This can promote laziness and minimized attention to detail, as well as inaccuracies concerning the doctor-patient encounter.

Automated EMR fill-ins of examination findings might benefit doctors in malpractice cases because “if it’s not documented, you didn’t do it” [think exams, tests]; and while I hate to see physicians get sued, the fact is there are some butchers out there, and EMRs may wrongly afford protection to some undeserved. Plus, inaccurate documentation can potentially harm patients by not providing an accurate representation of their condition.

If something adverse were to happen to a patient, the patient would be hard pressed to prove that the EMR is inaccurate because something may be documented as “normal,” when it’s abnormal. Or perhaps something wasn’t examined, nor maneuvered in order to be examined, but the EMR wrongly indicates the exam was done.

Under the Department of Health and Human Services, the Office of the National Coordinator for Health Information Technology (ONC) oversees the national rollout and implementation of EMRs. Their mission includes “secure and protected patient health information” and “coordination of care among hospitals, labs and physicians.” But I did not see any mention of “to assure accuracy” of the information that is so safely transmitted. What good is it to assure the records are safe and easy to share if the medical information itself is erroneous?

The ONC’s subcommittees include a Standards Committee, with its “Clinical Quality” subcommittee. I encourage them to add ‘accuracy’ to their national mission; and perhaps changes in EMR software are needed nationwide. Among other suggestions that space doesn’t permit me to express, I strongly recommend that adequate space always be offered for the physician’s narrative documentation of the patient’s chief complaint and findings. I also encourage patients to always get a copy of their records to do the best they can to assure that what the doctor enters accurately records what was told to them.

Medical records must be accurate in every way, every day; the profession and the patients deserve no less.

Melody T. McCloud is an obstetrician-gynecologist, public speaker and author of First Do No Harm: Healing Your Relationships using the Wisdom of Professional Caregivers and Living Well: The Woman’s Guide to Health, Sex and Happiness.  She can be reached on her self-titled site, Melody T. McCloud, MD.

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  • Jack Cain

    Dr. McCloud,
    Thank you for
    providing insight into this issue. My wife and I were rear-ended in April.
    Because our Primary is 15 miles away, the next day we went to a local Immediate
    Care facility because we could not tolerate the ride by public transportation
    to our normal provider. The doctor who saw us did not do an exam, and kept
    repeating that we should have gone to see our primary – no matter how much we
    told her that we could not tolerate the pain of going there. Later, she refused
    to submit her finding to my wife’s disability insurance, resulting in a denial of
    her claim. That led to her employer giving us 5 days to provide proof that she
    had actually been injured enough to need the time off our Primary gave her
    (about 6 weeks). I ended up sitting in her office and refusing to leave until
    she provided FMLA paperwork – which she filled in as “see primary”
    for all but one single entry. We did see our primary about two weeks later. Later, we found out that our
    primary wrote in his report that he “took the patient’s word for how much
    time she needed off” and again, he did not do a full exam either. He
    doesn’t seem to want to get any closer to us than about 4 feet at any
    appointment. So, we lost our only vehicle, my wife lost all of her vacation
    days, almost lost her job, and the insurance company is offering us $3,000 to
    settle the case.

    There are a lot of errors in my
    EMR, including diagnosis codes that don’t apply to me as well as incorrect
    weight measurements (entered in kilos instead of pounds, prompting a letter
    from our insurance on the dangers of obesity) and tons of prescription errors.

    • southerndoc1

      “I ended up sitting in her office and refusing to leave until she provided FMLA paperwork”
      I’d call the cops if anyone tried that in my office. No doctor is required to complete FMLA forms. Trying to get disability coverage based on a one-time visit to an urgent care center is really gaming the system to the max.

  • Elizabeth Rankin BScN

    I would think a benefit for patients besides reading their electronic record would be to have an adjunct to the record that requires patient input which would verify whether there is accuracy in what has been said to be done and to be able to verify or dispute the action, test etc. Narrative is essential. Perhaps the “Note” feature of the iPad could be used and integrated as part of the medical document.

  • http://www.facebook.com/laura.kolaczkowski.5 Laura Kolaczkowski

    Unfortunately, as an active patient/patient advocate, I hear this concern all too often. Medical records that aren’t complete or are erroneous happen often and your experience demonstrates that none of us are immune. I had errors in my record which listed a drug allergy I don’t have and it took me over a year to get it removed;and another one that still lingers that says I coronary artery disease. Once something is entered in an EMR it seems near impossible to get it removed or corrected.

  • southerndoc1

    Face it, folks. If you want your docs to do really accurate data entry, you’re going to have to get rid of all those distractions like history taking, physical exam, analytic and synthetic thoughts, emotional engagement, etc. that distract from what’s really important.

  • dsblanchard

    I have a PhD in Nursing and I just saw my sister go through a horrendous month-long process I can only now label as diagnostic espionage. She went to the new physician who took over the practice of our retiring family practice physician. In 8 years of exams, my sister was healthy except for being treated for hypertension which runs in our family. After her annual with Dr. New (pseudo-name), she was told (based on her blood work) that she had CHF and cirrhosis of the liver. Her blood work looked fine to me, but she cried for a week until I took her 30 miles away for a second opinion with a physician friend of ours who works in a MediExpress. He said there was absolutely nothing wrong with my sister. He looked at the labs and was incredulous that someone could construe such major chronic illnesses out of what he was looking at.

    My sister is seeing a psychiatrist and a psychologist for post-traumatic stress and spent a lot of time trying to ‘get to the bottom of her alcoholism’ based on the medical records he had accessed between her counseling sessions. These lapses in judgement, transcription or accounting (putting down a diagnosis to increase revenues) can really impact an individual’s life. Experiencing this with my sister really made me see how much.

  • midwestdoc

    This post is so true. There is a problem with the autofill that imports a normal exam. I saw a patient with severe hypospadius and the chart read “genitalia:normal”. My friend who is a dermatologist said that often when she looks at the referring physician’s note — It states “skin:no rashes.” In the old days (a few years ago), we would write or dictate and actually think about what we saw/heard/felt/observed for each specific area of the body. We were methodical about the exam and it was more accurate. I would encourage patients to look at the record and double check the accuracy.

  • Emily Lyons

    I keep wondering when we can just start submitting video in healthcare in place of much of our documentation! It seems like it is very out of date to be using subjective memory of the healthcare provider as to what took place when there are more objective ways to document. Yes, we would still have to document for interpretation.

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