Because someone rammed her SUV half-head-on into my car, this physician-surgeon has, of late, been a patient at physicians’ offices and outpatient surgical centers; and while medical sights, sounds, and sharp scalpels don't scare me, one thing I've discovered about electronic medical records does: They may not be accurate documentation of one's medical condition.

I love my profession. I am a stickler for accuracy, and I like reviewing patient charts. I always secure a copy of my own medical records simply because I like to be an informed patient. It was sometimes difficult to decipher some doctors’ scribble, but I discerned accurate documentation of my “HPI” — history of the present illness — as well as that of the exam performed, and pertinent findings.

But in this world of electronic medical (or health) records (EMR/EHR), I am no longer sure that such is always the case. [See related KevinMd.com and Atlanta Journal Constitution articles.]

EMRs are important, needed and helpful: physicians can review patient information that is typed and easy to access with the click of a mouse. But the physician's entries must be as accurate as possible.

My concern is not an indictment of my personal physicians; I wouldn't be their patient if I didn't have confidence in them. But as a result of securing copies of my records, and seeing records of others, I am very concerned that with the implementation of EMRs, not everything that is documented is actually being done. A few times when reading my records I said, “He didn't examine (or check for) that. He didn't do that.”

Fortunately I understand what I'm reading. I also know what should be done as part of each portion of an exam. The layperson doesn't have this benefit.

I fear that clinicians may rely on the EMR to literally “fill in the blanks” of examinations not done. This can promote laziness and minimized attention to detail, as well as inaccuracies concerning the doctor-patient encounter.

Automated EMR fill-ins of examination findings might benefit doctors in malpractice cases because “if it’s not documented, you didn't do it” [think exams, tests]; and while I hate to see physicians get sued, the fact is there are some butchers out there, and EMRs may wrongly afford protection to some undeserved. Plus, inaccurate documentation can potentially harm patients by not giving a true account of their condition.

If something adverse were to happen to a patient, the patient would be hard pressed to prove that the EMR is inaccurate because something may be documented as “normal,” when it’s abnormal. Or perhaps something wasn't examined, nor maneuvered in order to be examined, but the EMR wrongly indicates the exam was done.

Under the Department of Health and Human Services, the Office of the National Coordinator for Health Information Technology (ONC) oversees the national rollout and implementation of EMRs. Their mission includes “secure and protected patient health information” and “coordination of care among hospitals, labs and physicians.” But I did not see any mention of “to assure accuracy” of the information that is so safely transmitted. What good is it to assure the records are safe and easy to share if the medical information itself is erroneous?

The ONC’s subcommittees include a Standards Committee, with its “Clinical Quality” subcommittee. I encourage them to add ‘accuracy’ to their national mission; and perhaps changes in EMR software are needed nationwide, for more reasons than one. (ABC News’ Jim Avila recently reported that breaches had even been made in the security of EMRs, with some hospital staff members selling private medical information for profit.)

Concerning EMR accuracy, I strongly recommend that adequate space always be offered for the physician’s narrative documentation of the patient’s chief complaint and findings. I also encourage patients to always get a copy of their records to do the best they can to assure that what the doctor enters accurately states what was told to them. 

The doctor shortage is likely to worsen with the Affordable Health Care Act, even as doctors already feel great pressure to see as many patients as possible and to bolster their practice’s revenue stream. But to rush through the patient’s exam, and not confirm the point-by-point EMR automatic entries to which they affix their electronic signature is dangerous.

Although the practice of medicine has changed (and in my opinion, not always for the better), medicine is a noble profession consisting of mostly well-intentioned, dedicated, hardworking professionals. To aid in patient care delivery, EMRs can provide secure and expeditious transmission of information. But medical records must be accurate in every way, every day; the profession and the patients deserve no less.

Copyright © 2012 Dr. Melody T. McCloud. All rights reserved. Any excerpts reproduced from this article should include a hyperlink to this—my original post on Psychology Today, with author credit. Feel free to post the link to any of my PT posts, to your social network pages. Follow me here at PT (mostly), and Twitter: @DrMelodyMcCloud.

Living Well, Despite Catchin' Hell, a book about health, sex and happiness, with a foreword by Pauletta Washington, musician and wife of Academy Award winner, Denzel Washington; and endorsed by psychologist Dr. Jeff Gardere and others. The book includes current comparative data for Black, White, Hispanic, Asian and Native American women. This book also addresses the effects of negative stereotypes. (print and eBook).

Melodies of the Heart: Poems of Life & Love (eBook; poems about life, love, sex, death and more)

Medical Bloopers! Amusing & Amazing Stories of Health Care Workers (Illustrated; foreword by Dr. Neil Shulman, author of Doc Hollywood, now as an eBook)

About the Author

Melody T. McCloud M.D.

Melody T. McCloud, M.D., is an obstetrician-gynecologist and the author of First Do No Harm: How to Heal Your Relationships Using the Wisdom of Professional Caregivers.

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