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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