First, Do No Wrong

An NPR program on Friday 7/29/2010, which excited listener call-in interest, dealt with patients' rights to their own medical records.  Neither the moderator nor the program's physician consultants mentioned highly relevant federal law on this subject and this blog won't deal with that issue today. The program was short on significant statistics and long on testimonials of questionable value.

The program focused on an experimental New England medical teaching institution-based project to post patients' medical records on a secure internet site for them to review.  The proposed benefits included better patient information about what the doctor was thinking, the availability of records for patients to download and then provide to other doctors, and increased patient trust in physicians because of knowledge of what was in the record. No downside to this process was discussed.

For years, my practice habit was to always dictate my "progress notes"while the patient was sitting two feet away from me. The process took no more than 3 minutes and informed patients about my understanding of their relevant medical histories,  physical findings, interpretation of laboratory data and the diagnosis I had formulated, and my treatment plan and other issues which pertained to that visit.  Unlike the process of later posting the clinician's notes on the internet, my system allowed (the patient was invited to) patient correction of any errors and for me to make the correction or explain why I chose not to.  I had made it my habit to encourage patients (and often accompanying family members) to ask for clarification and for more information about the subjects I had discussed immediately after I signaled that my dictation had ended. When patients left my office, they were secure in their knowledge of what was (and was not)  in their  charts and additional requests by patients for copies of their records was unusual unless they needed records for medical care elsewhere.

The New England experimental program involving electronic health records has several downsides. Patients may self-censor the information provided to physicians and physicians may self-censor what they include in medical records.  Patients' reviews of the their records is deferred which may leave them with significant delay and unnecessary anxiety about what doctors thought. There is no timely patient-physician give and take with a chance for others (i.e., family members brought in by patients) involved in patients' care to participate in the discussion process. And, it takes strong physician training and discipline to provide a complete internet-posted electronic health record which even touches on serious issues such as interpersonal family relationships, the consideration of the possibility or presence of serious social diseases (such as HIV, syphilis, gonorrhea),  or situations, conditions or diseases which may result in deleterious insurer action, employer action, government action or adverse legal consequences.

Maybe we should slow down the use of technology, and bring smart social scientists into the process, so that we do no wrong.