I’ve clearly stated my views previously that I believe that patients should have full access to their medical records. Yesterday I read an interesting article, Patients Demand, “Give us our damned data.”
The first story in the article talks about a woman whose husband was transferred from one hospital to the other. She had to run back to get his medical records from the first hospital so that he could get adequate pain relief. The second hospital refused to give him pain medicine until they received his records from the first hospital. Most people would assume that the staff from the first hospital could fax the records over to the other hospital but that isn’t the way things work. The system for retrieval of medical records is broken and it long overdue to be fixed.
I have said before that I have a degree in Health Information Management. Once upon a time having been a supervisor and then a department director of a medical record department, I saw how hard it was to keep track of medical records. The strangest place I ever heard where some lost records in Texas were found was in the trunk of a medical resident’s care in Florida.
As described in the article there are other reasons for patients not being given their medical records. When I left the field of information management, only two hospitals in the state had electronic medical records.
It does not look like things have gotten much better. In many hospitals, only parts of the record are converted into an electronic medium. During my stays in the hospital as a patient, I saw nurses typing and clicking boxes online, then writing the same information in two different places.
I was in the hospital for a month with a deep venous thrombosis and by the end of my stay, despite their electronic checklists, they still didn’t have my medication correctly scheduled.
What happens when you are discharged from the hospital or you are seeing a physician at their office and you ask to receive a copy of your medical records?
As Ms. Cohen states in her article, there are federal laws that guarantee patients the right to their medical records. This does not mean that patients will receive complete copies of their medical records in a timely fashion.
If you try to obtain your medical records of a recent hospital admission, you will be directed to the medical records department. But as it is explained in the article, a clerk might tell you that you can’t have your records because they are not complete. They have usually 30 days to provide you with the medical record. As the article says, if you need the records more quickly because you or your loved ones are in another hospital, have the attending physician request the records. Hospital staff usually complies to requests when a patient has been readmitted to a hospital. But, unfortunately, sometimes hospitals do not get the records in a timely fashion to the other facility.
I’ve been behind the scenes. They aren’t lying when they say the record is not completed. Many records come down from the floor without signed orders, without discharge summaries because the doctor has failed to dictate them yet or perhaps the record is still in processing and it hasn’t been put in proper order and not all reports have been filed into the record. But after 30 days, it is reasonable to expect that the records should be complete.
Often the clerk will suggest if the record is incomplete that if you fill out a request for the medical records and write down the doctor they need to be sent to, they will send a copy of the records they have to the doctor who needs to see them.
If the clerk is able to make a copy of your medical record then you will be charged a fee. After all it cost money to make copies (not as much as they charge but of course you have to figure in employee time, etc.)
When you try to obtain copies of medical records, you soon get the feeling that perhaps they don’t want you to have them. That feeling you have is correct. Hospitals and doctors always point the finger of privacy regarding medical records. Afterall, they are trying to protect your records from falling into the wrong hands. But, these are your hands you say. What better hands to hold my record than my own? True, but doctors and hospitals really would you rather not have the information. There may be something in the record that you may “misunderstand” to be a medical error.
Also if your record has been flagged because it is under review for anything such as utilization of services, quality of care or especially any possible litigation, you will be told that your record is not available to be copied at the time you request it.
What can you do? As mentioned in the article there are many complaints to the Department of Health and Human Services. What can they do? Not much.
The even more difficult records that you may need to obtain are the records from your physician’s office. It is standard practice for office staff not to allow you to have copies of your records. They will tell you it is their policy to only forward records to another doctor.
What you must do is find out the laws in your state regarding your rights to your medical record. The laws vary from state to state and as Ms. Cohen points out, some states grant you less access to your medical records than federal laws allow.
Once you know what rights you have to your record if the doctor’s office or hospital refuses to give you a copy of your record, then it would be a good idea to print out the law of your state regarding patient’s rights to their medical records. You can usually find this information by googling laws in your state. If you can’t find it, there should be a number that you can call listed on a state’s web page or call your local library.
After you have printed out the information, then “politely” demand the right to your records. As Ms. Cohen says, you may have to get “mean.”
As I stated above, your record may be flagged because it is to be reviewed by a committee for possible misuntilitization of services or a medical staff error involving your care.
I was admitted to the ER and overdosed with anti-emetics which caused me to come back to the hospital having major spasms and tremors. We made a complaint to the hospital and I was not initially given access to my medical records until after we went to a scheduled meeting with an administrator in which he graciously apologized.
You may not even know a mistake has been made. Hospitals are required to perform reviews on some records in which they find “medical mistakes” even if there was no adverse outcome to the patient. So you may not even know there was a mistake. If you receive a vague answer as to why you cannot receive your regards according to federal and state laws then I suggest you keep going up the chain of command until you find someone who is willing to discuss why your record is not available. If you have to make an appointment with an administrator so be it. Also, in the case, the squeaky wheel theory does apply.
As for physician’s records, you may have done everything you possible can do to get your entire medical record and you may only end up getting a few pages of records. This is because the doctor doesn’t really want to give you anything and you can’t prove what was in the record and what was not. The main thing I am interested in when I obtain physician’s records is a summary of the visits and copies of all tests.
I thought when I had to leave the health care profession 13 years ago that by now physician’s offices and hospitals would surely have complete electronic medical records. I read the other day on average many states only have 13% of their medical records converted to entire medical records.
There are many reasons for this such as lack of doctor cooperation, hospitals having many different computers that can’t communicate with each other etc. Physicians with office practices complain that it is too expensive to convert their medical records to electronic form but they really haven’t looked at all the possibilities.
There have been models of patient centered care in which the patient owns his or her complete electronic medical record and is able to carry it with them on a thumb drive. The patient is in charge of their own records and can give information to who they want to give information to when they want to. The results are promising. Patients feel much more empowered as a team player in their medical care.
The government says that all medical records will have to be converted to an electronic form by 2014. I hope that before then this growing grass roots movement of consumer based health care will direct that electronic medical records are a necessity and that everyone should have access to their medical record at all times.
Data that will be able to be generated by web based software from electronic medical records will help patients and doctors to be able to come to the right diagnosis quicker and provide information for the best paths for treatment. This information will also show patterns in the way hospitals and doctors practice medicine and then people will be able to truly find the right doctor to provide the best diagnosis and treatment for their illness.
I suggest you watch this video on this page: The Quantified Patient. One man talks about his journey obtaining medical information and treatment for his kidney cancer.
