This year, I’ve had many experiences with the evolving rules and regulations regarding patient privacy and electronic medical records. Although some have been positive — streamlining doctor-to-doctor communication, for example — some have been frustrating and cautionary.
As health care privacy rules are more stringently enforced, and electronic records become the norm, there are several points to understand, and steps each of us can take to ensure that, especially at critical moments, we and our health care team have the correct information we need to make informed and appropriate decisions.
One of the most important aspects of patient privacy is that unauthorized people do not have access to any of our personal health information. In general, this is good. We all cherish our privacy. However, in some cases, it can pose problems.
For example, if you are a caring for an aging parent, unless there is specific documentation that you are authorized to obtain medical information and/or participate in his or her care, health care providers may not and, in many cases, will not include you in the information loop.
It is important to have the correct documentation on file with the medical team as soon as you take on the role of caregiver. Also, do not assume that because information is on one form at the doctor’s office that it has carried over to other health providers’ offices.
You need to physically carry your paperwork to each health care venue to be sure your status is documented properly and clearly.
Effective health care electronic records should be correct and complete. I regularly ask for copies of my records so that I can easily correct errors. However, if you provide care for someone else, this might be more difficult, but no less important.
My father suffered from dementia. A few months before his death, he was admitted to the hospital unexpectedly. Unfortunately, the attending physician took a medical history directly from him and recorded it in the electronic file. Much of the information was incorrect. Some of it was critical (such as drug allergies and current and ongoing medical conditions). I caught the errors, but the hospital would not correct them without going through an elaborate appeal process that entailed a review by the hospital administration and a panel of doctors.
This process also was required to correct one of the emergency contact telephone numbers (mine) that had been documented incorrectly. It took time, but I communicated directly with the health care providers so that the right information was in the right hands immediately.
Beyond our personal use, “alternative” uses of our health care data can more easily creep into the forms we regularly sign at our doctors’ offices, clinics or hospitals. Thus, reading through them carefully before signing them is even more important. At a recent appointment at a teaching hospital, for example, I was given an iPad on which to enter answers to medical questions to “update my file.”
As I got to the end of the series of questions, I was asked if my information might also be used “anonymously” for research purposes. How “anonymous,” I wondered? And for what research? I declined.
Rather than wait for a medical emergency, take time now, before the emergency happens, to make sure that health care records are up to date and that the appropriate people have the documentation they need to advocate for us or others. Advance preparation, vigilance, and attention to detail also are good for our health.
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