As healthcare organizations prioritize patient safety, they must assess how patient requests for EHR corrections add up.
Patient safety has proven a key goal in healthcare, with many organizations setting a zero harm goal. And with the advent of EHRs and other health IT platforms, organizations should consider how patient requests for EHR corrections fit into the patient safety puzzle.
The EHR has represented a key path forward in the digital health realm, often being credited with improving patient safety and streamlining care.
But these tools are also fraught with issues. EHRs are largely viewed as the leading cause of clinician burnout and can sometimes be home to the same erroneous medical notes that older, paper-based records were. The EHR is operated by humans, after all, and is therefore liable to human error.
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The important thing to remember is that these mistakes can be corrected, and while clinicians need to keep a careful eye out for errors that they need to fix, the patient can also play an important role in this.
In addition to boosting patient engagement and activation in care, patient data access is instrumental for improving patient safety, experts say.
By understanding requirements for patient requests for medical record corrections and working to encourage patient data access and review, clinicians, hospitals, and health systems can empower patients as partners in their pursuit of healthcare safety.
Requirements for patient-initiated medical record changes
Requesting an amendment to a medical record is a HIPAA-mandated patient right that all covered entities must follow. Patients may request changes where they believe there are inconsistencies, and healthcare providers or payers must assess and respond to patient requests.
“If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request,” HIPAA states. “If it created the information, it must amend inaccurate or incomplete information.”
A covered entity may review the request and make the amendment, or in some cases deny the request. Patients reserve the right to submit a statement of disagreement that the provider or health plan must add to the medical record.
But addressing that conflict should go beyond adding that statement of agreement. A patient may believe there is an error in her medical record when there is in fact not. Clinicians should take this as a signal that patient education fell short somewhere along the way, according to experts from the University of Washington School of Medicine.
“Requesting patient feedback to clarify potential misunderstandings may better inform the doctor about the patient’s level of understanding of her health and the care plan,” the UW researchers wrote in a previous paper. “Encouraging patients to reflect on the visit afterward may uncover missed information, improve mutual understanding, and strengthen a sense of partnership. Thus, in addition to improving patient–doctor rapport, this type of feedback has important patient safety implications.”
If a patient believes she takes a certain medication where she, in fact, takes another, clinicians should take this opportunity to review medication safety issues with the patient in a compassionate manner.
Encouraging patient medical record review
Of course, for a patient to catch a clinician note error and then request a correction, the patient must first feel empowered to read and review her medical records.
A 2018 report from the Office of the National Coordinator for Health IT revealed that about one-quarter of patients reviewing their health records request some sort of error correction. That’s not an insignificant proportion – many patients may not be requesting a correction simply because there is nothing that needs correcting.
The trouble is, that one-quarter comes from a fairly small sample size. Very few patients are actually reading their medical records, meaning few are able to pick up on any clinician note errors. Said otherwise, the challenge is not encouraging patients to report a health record error; the challenge is getting the patient to read the health record at all.
Data from a 2017 GAO report confirmed that nearly 90 percent of hospitals and physician offices give their patients access to a patient portal, but only about one-third of patients use the tool.
Clinicians need to do more to encourage patients to review patient portal information, ultimately empowering those patients to discuss the record and any potential errors with their providers.
“Electronic systems that notify patients when notes are available can substantially increase reading rates,” the UW researchers suggested.
“By personal preference, some patients will choose not to read their doctors’ notes. This may be particularly true for patients with less education, poorer self-reported health, and poor health literacy. Involving family, friends, or health navigators in the dissemination of notes should be considered, but further research and innovation is needed to encourage all patients to examine the benefits of viewing notes.”
Patient requests for corrections improve patient safety
Getting the patient involved in understanding and potentially correcting the medical error is having positive impacts on patient safety, previous data shows. Groundbreaking 2016 study from OpenNotes showed that giving patients the power to annotate their medical records and calling attention to what they believe are errors can increase safety.
The researchers introduced a feedback tool to 41 physicians who had already adopted the OpenNotes philosophy. Through this outreach, 6225 patients used the tool over the test period from August 2014 to August 2015.
Overall, 44 percent of participating patients looked at their notes, and one in 12 (about 8 percent) of patients used the feedback function, according to a report published in BMJ Quality and Safety.
The feedback tool proved effective for citing inaccuracies, which may help to avoid negative patient safety events. Of the patients who used the feedback function, 23 percent reported safety concerns, usually pertaining to medication errors or misreporting of pre-existing health conditions.
Sixty-four percent of feedback reports were categorized as confirmed or possible concerns. Eventually, 57 percent of the reports resulted in actual changes to the medical record.
“Our findings add to a growing literature suggesting that patients can help identify mistakes,” said lead author Sigall Bell, MD. “We were struck that nearly all patients and care partners in the study found the feedback tool valuable. What that indicates to us is that patients are eager to help their health care teams ‘get it right.’”
Getting the patient involved in the medical record has proven difficult for healthcare providers. While the EHR is accessible for patients through the patient portal, very few are actually flocking to look at their own health records.
As patient safety continues to be a key goal in healthcare, providers may consider strategies for encouraging patient data use and empower patients to alert their providers where there may be errors. In doing so, providers can have an extra check on patient medical information, ideally ensuring a better patient experience.
Source: Patient Engagement Hit