Secrets Behind Your Medical Records

By: Red Hot Mamas

Published: January 16, 2012

Medical Records

It happens every time I visit the doctor. He sits across from me, secretively writing in his secretive file with his secretive pen. He listens closely as I explain my symptoms and sometimes nods his head or briefly makes eye contact, but his pen never seems to stop moving until the physical examination. So what are these secretive doctors writing down about us anyway?

Researchers at Harvard University Medical School and the Beth Israel Deaconess Medical Center in Boston recently decided it is time to allow patients access to the doc’s written notes in their charts. In a recent study, they created a new system called Open Notes and invited patients to take a look. Of nearly 40,000 patients in Boston, Seattle and rural Pennsylvania, 90% wanted to see their primary doctor’s written notes.

With access to their records, over half the patients in the Open Notes study thought they would take their medications better if they were taking any, and 90% felt they would be in more control of their care. If given the opportunity to read their notes, at least 80% of patients felt they would take better care of themselves and gain greater understanding about their medical situations.

Many doctors didn’t like the idea of sharing their notes. Some doctors can make it difficult for patients to get ahold of the medical notes that we are legally allowed to see. According to a recent poll of 100 primary care doctors nationwide conducted by Truth On Call for msnbc.com, 68% of physicians have written something in a patient’s chart they wouldn’t even want that person to see.

Not surprisingly, many doctors did not want to participate in the Open Notes study. Of 254 physicians asked whether they would be willing to make their office visit notes freely available to patients in their electronic health records for one year, 114 agreed and 140 declined.

What are they hiding in their medical folders anyway? Office visit notes are supposed to include the patient’s medical history, a record of what was discussed at the appointment and sometimes the doctor’s insights into patients’ prognoses and guesses about what might be ailing them. It’s not that I’m paranoid (does he think I’m a hypochondriac?), but this is my health and my record and I should be actively involved in my care.

All signs seem to be pointing to electronic medical records anyhow. In 2009, the US Government set up a system of incentives as part of the Recovery Act to encourage health care providers to convert to electronic medical records systems. The first of those incentive payments will be issued in the first 6 months of this year. Other places have been implementing the use of electronic medical records for a while. At the University of Texas, patients have had access to their electronic records for several years now.

The Office of National Coordinator for Health Information Technology (ONCHIT) reports 74% of hospitals they surveyed say they are planning to invest in health information exchange services. In addition, ONCHIT has commitments from 100,000 rural doctors to adopt the system, which is a great feat as in the past, rural doctors have been viewed as the toughest to convert to electronic medical records. Many systems available now even come with iPads for doctors to take into each room.

With the movement towards electronic medical records, I don’t think we’ll be trying to sneak a peek at our doctor’s notes anymore. Instead, we will have access to our online account and have the ability to see their notes right there. Until then, you could take a tape recorder or video camera to your next visit to review the conversation later. The notes would still be hidden, but revisiting the appointment will help you understand the conversation and ultimately make better future decisions. Because communication and better health outcomes is what it’s really all about, right?

Next year, researchers from the Open Note study will report back on what happens when doctors and patients actually get on the same page. I know doctors usually know best, but I also feel that I should be kept in the loop.

From another perspective, however, if patients are allowed to see doctors’ notes, they may not understand the medical lingo. This may create some fear if they are not able to comprehend some of the words.

And, some more food for thought, when the doctor knows his/her notes will be read, perhaps he/she will only write what would be useful in case of litigation. There may not be any hypothesis raised, because of the fear of litigation. Which may make us think, why are we not able to read the notes of lawyers? I know many doctors would love that.

References
Cloninger, Ashley. “Healthcare Providers Continue to Move Toward Electronic Medical Records | Wall St. Cheat Sheet.” Wall St. Cheat Sheet | Financial News for Investing, Business, Trading, Stocks, and Entrepreneurs. Web. 16 Jan. 2012. Website.

Park, Alice. “Can Patients Handle the Truth? Getting Access to Doctors’ Notes.” Healthland | A Healthy Balance of the Mind, Body and Spirit | TIME.com. Time, 20 Dec. 2011. Web. 16 Jan. 2012. Website.

Rabin, Roni C. “Project Puts Records in the Patients’ Hands.” Nytimes.com. The New York Times, 9 Jan. 2012. Web. 16 Jan. 2012. Website.

Taylor, Kimberly Hayes. “Do You Really Want to Know What Your Doc Is Writing about You?” Vitals. 19 Dec. 2011. Web. 16 Jan. 2012. Website.

Zeiger, Roni. “Should Patients Read Doctor’s Notes? Wrong Question.” E-patients.net. Society for Participatory Medicine, 17 Aug. 2010. Web. 16 Jan. 2012. Website.

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