Thursday, April 9, 2009

Your Chart: Do you know what's in there?

This is a wonderful post over at The New Life of e-Patient Dave's website about electronic health records. I strongly encourage patients and clinicians to read it. While there has been much debate about whether EHRs actually improve patient care and save money (I believe they will do both) the move to electronic records will enable transparency when it comes to viewing and reviewing your own chart.

Have you ever tried to get a copy of your own record? It is not exactly the easiest process. Most providers offices require you to complete a records release form which is filled with legal jargon and makes you seriously question if you really want to get these records in the first place. Some providers charge you per page to photocopy your record and good luck in thinking that this will be processed promptly by the staff. Once you get your hands on a traditional paper chart copy, it is nearly impossible to decipher. Is this acceptable? Maybe accessing your health record should be like getting your credit report. I know that in a matter of seconds I can log on to one of the credit reporting websites, enter some information and have complete access to my full credit report.

So now that you have access to your chart, I am reminded by the Seinfeld episode, "The Package" where Elaine has a rash and sees a few doctors only to be shunned by what is written in her chart:

Should patients have the right to question what's in the chart or make their own comments? Can subjective data be debated? Would clinicians document differently if they knew that patients had unfettered access to what's in there? Is our system of charting archaic and does it truly capture the essence of the visit? Could we be making better use of technology and snap digital photos of certain conditions and attach them electronically to the record? If we are to be patient-centric, how much input should patients have in their records? Would clinicians have to "defend" their charting if questioned? These are many questions that could make for some interesting debate. What do you think?

I think we have a long way to go when it comes to transitioning to electronic records. Yet, the time has come. We need to stop talking about it and thoughtfully start implementing it. It all goes back to communication and understanding about disease processes and steps that can be taken to improve health. After all isn't your health record just as important as your credit score?


Jennifer said...

Great post! Very good points, I will share this with my facebook friends.I am adding you to my blogroll, I found your blog through npbo. Will keep up with your posts as a fellow NP.
Jennifer Butler,FNP

Anonymous said... will be happy to know Carolyn was in last week to train us on our new EHR...yes we are going to electronic records..lots of work ahead with the usual suspects..(per-diem stuck in the past) but I am committed...waited a long time to get excited!!!!