Clinicians need to take back ownership of the medical record, and a cautionary word on privacy from a psychiatrist

Clinicians need to take back ownership of the medical record, and a cautionary word on privacy from a psychiatrist

Douglas W. Blayney, MD, FASCO

Mar 24, 2010
An article by Schiff and Bates, writing in the March 25th New England Journal of Medicine, here caught my attention. They make some suggestions to answer the question, "Can electronic clinical documentation help prevent diagnostic errors?" They start with the premise that "electronic prescribing appears to reduce the rate of medication errors, but the other benefits of electronic records are less clear," and go on to suggest ways in which EHRs can diminsh diagnostic errors:
  1. Filtering, organizing and providing acces to information...the problem of having too much information is now surpassing that of having too little, and it will become increasingly difficult to review all the patient information that is available.
  2. Serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtul differential diagnoses, and note unanswered questions.
  3. Facilitate the documentation of evolving history and ongoing assesment.
  4. Managing problem lists ... The failure to effectively integrate the creation, updating, reorganization and inactivation of items on problem lists into the clinician's workflow has been one of the great failures of clinical informatics.
  5. EHRs should ensure fail-safe communication and action in the areas of ordering tests and tracking the results.
  6. Electronic systems should incorporate checklist prompts to make sure that key questions are asked and relevant diagnoses considered.
  7. Electronic systems should do more to help with follow-up and the systematic oversight of feedback on diagnostic accuracy.

They conclude with the observation that "clinicians need to take back ownership of the medical record as a tool for improving patient care."

Needless to say, I agree. Our current medical records serve the purpose of billers, auditors and attorneys. They communicate poorly amongst the patient care team, and don't facilitate recording of pertinent observations, highlighting them and annotating these observations. Both in the paper and in the electronic world, there is too much cut and paste or re-dictation of previously recorded information. Record creation and review has turned into a time-sink with minimal value creation.

In addition, psychiatrist Deborah Peel, in an op-ed piece in today's Wall Street Journal (here) entitled "Your Medical Records Aren't Secure" and with the sub-head "The president says electronic systems will reduce costs and improve quality, but they could undermine good care if people are afraid to confide in their doctors," makes the point that security breaches and other data leaks could undermine patient's confidence in their doctors and their associated EHRs.

I suppose a psychiatrist, because of the problems with whiche she deals, would be especially sensitive to this issue, but she alerts us all. In the system in use where I work, accessing sensitive information (HIV results, HLA typing, psychiatry consults) is preceeded by a pop-up warning that access is being monitored. We have had at least two people terminated from employment in our cancer center in the recent past for breaching fellow employee's medical records, so the audit trail system does work. However, I can see Dr. Peel's point; I remain concerned about security breaches. Perhaps some of the stimulus borrowing money can be put to use beefing up patient-related information security systems as Dr. Peel suggests.


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David A. Hanauer, MD,MS

Apr, 06 2010 2:11 PM

The concerns about patient privacy raised in the Wall Street Journal article are important for healthcare organizations to start thinking about more. I am sure that the issues will only grow larger as an increasing number of physician hospital practices switch to EHRs. As healthcare providers and organizations we must be doing everything we can to ensure the safety of not only the patients themselves but their clinical data as well. If not, patients will refuse to accept that their data may be used for other purposes such as quality improvement and research, all vital to improving our overall healthcare system and the health of our population.

Additionally, the concern about patients potentially not wanting to make their data available for secondary uses reminds me, to some degree, about the vaccine arguments that are sometimes made. Some people in the community don't want their family members to be vaccinated due to concerns that are far out of proportion to the risks (vaccines are generally extremely safe).

Both vaccines and the need to use clinical data for quality improvement and research are public health issues, and therefore we have to consider that there may be some personal responsibility that individuals must take to have their families vaccinated (resulting in the positive benefits of 'herd immunity') and to allow their medical data to be used (resulting in future discoveries that will improve the health of our population).

There are ways to mitigate the concerns that patients may have about each of these issues. For vaccines, education is key, as well as our national surveillance program through the CDC--the Vaccine Adverse Event Reporting System (VAERS), for example. For clinical data, good data use practices (e.g., not storing clinically sensitive data on an unencrypted USB drive) as well as infrastructure security are important. Future technologies may also include de-identification of free text documents so that even those individuals who have a 'right' to view the clinical data for quality and research won't know who the patients are. This will increase privacy and hopefully mitigate some of the concerns about the secondary use of clinical data.

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