Wouldn’t it be nice if the advent of EHRs made it more likely that information in medical records was accurate? Sadly, that’s hardly the case.
In fact, patient matching issues actually seem to make it more likely that the wrong patient data makes it into a chart. Add problems with busy physicians making the occasional cut-and-paste error, and you can have a real mess on your hands.
I was thinking about this today when I read the story of Morgan Gleason, a woman who went through a struggle to get documentation of two non-existent pregnancies out of her medical records. Gleason, who suffers from a rare autoimmune disease, is a pro at managing her health, but had to fight hard to correct these errors, according to a CNBC story.
Gleason’s tale begins two years ago when she requested her medical records after a visit to a Florida women’s health clinic. With the help of her mother, who worked at health IT firm CareSync, Gleason stored all of her medical records in one place once she received them.
When she received the clinic records, she was surprised to find notes saying that she had two children, one living and the other having died shortly after being born. Gleason had never been pregnant.
Unfortunately, this wasn’t the first time she found a serious mistake in records. In the past, she told CNBC, a diagnosis of diabetes apparently popped up in her records, which was also erroneous data.
In this case, when she called the clinic to report the error an assistant on the other end of the line told her that she was wrong about her own medical history.
Gleason told CNBC that the assistant simply wouldn’t listen to her. “If you hadn’t told us this, there’s no way this could have been in your chart,” the assistant reportedly told her. The clinic didn’t change the record until Gleason made a formal request for it to be changed.
I can understand why the clinic might have wanted the changes to be requested in writing. Changing a patient’s record does have legal significance. At the same time, though, providers should have an easy-to-explain process in place for making appropriate changes.
In my view — particularly as someone with chronic illnesses — it’s inexcusable when an institution makes it hard for patients to correct mistakes. On the contrary, medical practices and facilities should be delighted if someone does the quality control for them, rather than leaving them open to liability when they make mistakes based on incorrect documentation.
Now more than ever, it seems to me to the culture of resisting patient interaction with their records has got to go. If you’re not sure how patients are treated when they make such requests, I encourage you to try and make such changes yourself and see how far you get.