The advent of electronic medical records will, in the long run, prove to be a good way to improve the healthcare we get. However, between new processes for development of the records, the transfer of current records to these new electronic systems, and the way these new systems are being used to share our medical records, it seems clear that the use of this new digital technology may lead to more or different medical records errors than ever before. And mistakes in our medical records can have a very negative impact on our lives.
1. Transfer of Paper Records into New Digital Records
As more and more of our medical records are being transferred from paper to digital, one problem doctors and facilities are running into is determining how much of that information needs to be transferred. The needs will vary from patient to patient, from specialty to specialty, from medical problem to medical problem, and more.
Depending on factors like your age, your chronic health problems, your vaccination record, allergies and other attributes, more or less of your medical record will be moved to your digital record. Much of the information is being transferred through scans of paper records. As long as the scans are clear, and as long as the information contained in those paper records is correct, then that information will be accurate. But mistakes already exist in many paper records. And some of that data is being transferred by human beings, meaning plenty of opportunity for mistakes to be made or compounded.
You'll want to keep track of whether your doctor's office, or hospital, or lab, or other facility has made the shift to using an electronic health record for you. If it's not readily apparent, then ask. Once you know the shift has been made, ask to be able to see what your record looks like so you can determine if any of your medical record needs to be corrected.
2. Record Sharing
Technology, and the use of digital patient records, makes it very easy for one doctor or facility to share your records with another. For the most part, that's a good use of digital records.
But a few problems will result from this sharing of records, and in some cases, your review of your records can prevent these problems.
The first problem is that when a mistake is made, but not caught, it can create a ripple effect of problems. For example, say your blood type is A+, but somehow, when it was scanned, or put into your record incorrectly, it came out as A- (the scan may not have been clear, or the data converter made a mistake.) No one catches the mistake and it's not corrected. At some point you need a transfusion and - yes - you might get the wrong kind of blood. Previous to electronic records, they might have typed your blood just prior to the transfusion. But in an emergency, they might not take that time.
Secondly, a mistake in the identification sections of your record can result in more than one record for you, neither of which is complete. Your records are being scanned and developed in many different doctors' offices and facilities. Eventually they will need to meld into one record - one patient, one record. Maybe you got married and took your new spouse's name. Or maybe you were divorced and returned to your maiden name. Or maybe you are using your middle name with one doctor, and no middle name for another.... Unless you check your records, you may not know that more than one exists. From then on, you'll have extra records being amended by many doctors, creating an impossible mess, and possibly having a negative impact on your healthcare.
3. Current Records - Transcription Problems
In the "old" days, our doctors sat down to a transciption machine, dictated notes about our appointments and test findings, then sent off those little tape cassettes to a local transcriber who would listen to the dictation, type up the notes, and return them to the doctor's office for filing.
Fast forward to today. Because your medical record will be electronic, your doctor dictates notes into his computer or a handheld device that creates a digital file. The digital file is then transferred by Internet to a transcriber. The transcriber might type up the notes, but more likely the transcriber uses some form of software that "listens" to your doctor, then creates a written report of your visit. This software, called "speech to text" software, is mostly accurate, but not entirely. Mistakes are often made with everything from the patient's name, to the names of drugs - easily mixed up drug names - to the names of treatments, even diagnoses.
The transcriber should then review, looking for mistakes to correct. However, those transcriptionists aren't always native English speakers. They may actually be located in countries where the cost of labor to transcribe is less expensive than English-speaking countries.
The now-text files, whether or not they have been accurately reviewed and corrected, will be returned to your digital files. Maybe your doctor will see them, or maybe not. Most don't have the time.
Those records might be full of mistakes. Unless you uncover them and correct them yourself, those errors will remain - and will replicate.
How can we protect ourselves from medical records errors?
It's up to us patients to review our records and correct them.