I didn’t know it was so easy to be 10 years younger, an inch shorter or lose extra body parts. But when reviewing my medical records that’s what I found.
This component of health reform hasn’t received a lot of attention. I’ve heard directly from several doctors about the extra time e-records take and their problems finding appropriate software. But there is no doubt electronic records are the future of medical record keeping. E-records should make it easier to get information quickly to hospitals and specialists; it could reduce the need for duplicate tests. Sounds good until you realize it falls to you to ensure a measure of accuracy.
Some specialists make it easy to review our basic medical history because they send us follow-up letters. One would think that the pages and pages of history that we fill out by hand would be part of our record, but too often that does not happen. Maybe in the future we will be able to fill out forms on-line. We seek medical care for our benefit and the records and test results are for our benefit too. We have the right, but should also have the obligation, to review those documents for our own sake and to also reduce health care costs.
How many times have you asked for a detailed print-out of your hospital bill? Did you show it to your doctor? While some items may be hard to decipher (ask for an explanation), others are not. Twice, in separate incidents, I found billing mistakes of up to a few thousand dollars. Frequently the mistakes involved medications—they were ordered if needed, but were never administered. When I showed one bill to my surgeon, he discovered a particular suture had been billed at $200. It should have been $20. Most interesting was the attitude of the (private) insurance companies; when I alerted them to the errors, I was told that unless the mistakes were over a certain amount, they wouldn’t bother with them.
Much simpler to review is the basic information of our age, height, weight. How can these statistics get mixed up and what are the consequences? In my case, my height was plugged into a Body Mass Index program and automatically displayed in my chart. Left uncorrected, I would be listed as obese.
As for missing body parts—so what? Long ago I met a lady who was scheduled to have gallbladder tests even though she no longer had one. Apparently her doctor didn’t have her records and she didn’t understand the nature of the tests. That resulted in an expensive, unnecessary test. Missing ovaries is more serious. If records show they’ve been removed--when they really haven't--are primary care doctors more likely to skip that part of the annual exam that could pick up ovarian cancer?
Most doctors I’ve encountered are glad to have our records corrected. However, one chance meeting with a physician recently wasn’t so encouraging. This MD was indignant when I used the term ‘client.’ She didn’t think that business model terminology should be included in the medical field. She also said that while the patient could add notes in his/her file about perceived mistakes, the records couldn’t really be edited—only added to.
This is a bit hard to believe. I’d hate to think the corrections I make in my file will be placed on some bottom page where few would read them. Whether editing our e-records is problematic or not, it’s past time we took ownership of our medical information.
Maybe health reform should include the requirement that we all review our records for accuracy and completeness. This added step could benefit us in the future, perhaps in an emergency, when we would be least able to do anything about it. It might even save money.