In a perfect world, an electronic medical record would aggregate a patient’s medical information from all health care providers into a single, comprehensive record that could be easily accessed by any provider with the patient’s permission. This information could reduce the risk of medical errors, duplicate testing, and inappropriate treatment and the associated cost of these mistakes. It could also be lifesaving in the event of a medical emergency that left the patient unable to communicate with providers. But, of course, the world is not perfect, and neither are electronic medical records.
Errors in electronic medical records and systems occur more frequently than many patients know. A Kaiser Family Foundation survey noted that one in five people surveyed reported finding an error in their electronic medical record. The errors included incorrect personal information and incorrect information about medical history, diagnostic test results, and prescriptions. Quantros, a health care analytics firm, reviewed data from 18,000 safety events related to electronic health records over an 11-year period. Of those events, 540 caused patients harm, and seven deaths resulted.
Medications are another hotspot for errors. A report from Castlight Health and the Leapfrog Group found that approximately one in 20 patients in the hospital experiences an adverse drug event. In 39 percent of the cases reviewed, the hospital’s online system did not flag potentially dangerous orders. A study in the journal Patient Safety reported that health information technology was listed as a contributing factor in 889 medication error reports submitted to the Pennsylvania Patient Safety Authority over a six-month period.
There are several causes for these errors, including:
- Health care provider error (inputting incorrect or incomplete information, cutting and pasting incorrect information, misidentifying patient)
- Electronic health record (EHR) systems that do not communicate with each other, which can lead to fragmented and incomplete records
- EHR system failures
- Lags in data (such as test results, new prescriptions, and hospitalizations) being updated
Steps to lower the risk of errors in your electronic medical record
There are several steps patients can take to reduce the risk of medical errors related to problems with electronic medical records:
Be a proactive partner in your care. Regularly request a copy of your records from all health care providers you see, including primary care, specialists, urgent care, hospitals, and outpatient or ambulatory care centers. Start by ensuring that all the basic information is correct (name, address, date of birth, Social Security number, health insurance information, emergency contacts). Then review your medical history (allergies, symptoms reported, diagnoses, prescription medications, diagnostic test results, medical and surgical procedures performed). Check this information to ensure it’s current. For example, does your record still list medications you no longer take?
Have a medical home. Having one health care provider who acts as your point person can help ensure not only that the care you receive is coordinated among providers but can also help keep your medical records consolidated. Choose a provider you see regularly, usually your primary care provider, to act as your medical home. You’ll need to let your provider know what other doctors you see and have those providers share your records and test results with your medical home.
If you find an error, get it corrected. If you do note an error in your medical record, contact the provider and ask what the practice’s or facility’s procedure is for making a change to your record. Some providers use a form — or you can write a letter that outlines the error, provides the correct information, and includes a copy of the page of the record with the error highlighted.
Providers have 60 days to correct an error, although they can request an extension. Your provider should send you a notification that the error has been corrected. After the 60-day period, request a corrected copy of your record and review it. If the provider does not agree that there is an error, he or she should send you a denial notice, explaining why the correction is not being made. You can respond in writing, explaining why you don’t agree with the decision, and a copy of your letter should be included in your record.
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